The Netter Collection of Medical Illustrations VOLUME 1 Reproductive System

Plate 4-11 Reproductive System

6

CARCINOMA OF PROSTATE II: 6 Scapula 8 Cervical 2
METASTASES 3 Sternum 1
3 Tracheobronchial
In 10% of patients at presentation, prostatic carcinoma Supraclavicular
reveals contiguous spread to other organs (see Plate
4-10). However, with aggressive early detection strate- Infraclavicular
gies currently used, far fewer patients exhibit metastases
to distant sites. When it occurs, prostate cancer has an 5 Ribs
overwhelming predilection to metastasize to bone. It is
thought that this unique metastatic pattern is due to the 1 Spine
fact that (1) circulating prostatic cancer cells may be
found early on in the life span of the cancer and (2) 7 Mediastinal 1 7
metastatic cells tend to be arrested in cortical and med- 6 5
ullary bone spaces. Tumor expansion in bone may cause 2 Pelvis
pain, compression, pathologic fractures, and anemia and sacrum Gastric 7 3
due to bone marrow replacement. 4

The pattern of bony metastases in prostate cancer Hepatic
also occurs in a fairly characteristic manner, with
involvement of both the axial and appendicular skele- 6 Pancreatic
tons, typically the pelvis, sacrum, and spine, observed
most commonly. This metastatic distribution may be a 5 Mesenteric
consequence of pelvic venous drainage through Batson
plexus, a network of valveless veins that connect the 4 Femur 2 Paraaortic
deep pelvic veins draining the inferior bladder, prostate, 1 Iliac-obturator
and rectum to the internal vertebral venous plexuses.
Because of their location and valveless nature, they are 4 Inguinal
thought to provide a route for the spread of cancer
metastases from prostate and colorectal cancers. From Lymph node and visceral metastases
this landing zone, cancer may then spread to the verte-
bral column or brain. The plexus is named after anato- Node groups numbered in order of
mist Oscar Vivian Batson, who first described it in frequency of involvement, with relative
1940. The sites of bone involvement are illustrated in incidence indicated by dots. Most
the frequency with which they occur. commonly involved viscera numbered
in order of incidence.
Prostate cancer involvement of visceral and soft
tissue nodal sites is less common than bony metastases. Bony metastasis
In patients with hormone-refractory prostate cancer,
bony involvement can be found in 85% of patients, soft Sites numbered in order of frequency.
tissue or nodal involvement in 25%, and visceral metas- Dots without numbers indicate
tases (mainly to lung and liver) in 18%. Although not less common sites.
as characteristic as bony metastases, the approximate
sites of visceral and soft tissue nodal involvement are be observed until 5 years after micrometastases have false-negative results; specificity is improved when com-
also illustrated in the frequency with which they occur. developed. Abdominal or pelvic computed tomographic bined with CT scans. Depending on the urgency and
(CT) or magnetic resonance imaging (MRI) scans need for treatment, bony metastases from prostate
Bony metastases from prostate cancer, when viewed may reveal extracapsular extension, seminal vesical cancer are treated with androgen deprivation therapy in
on plain x-rays, appear osteoblastic. The metastasis has involvement, pelvic lymph node enlargement, liver naïve tumors and generally respond to radiation therapy.
a “snowy” appearance because of an increased deposi- metastases, and hydronephrosis (due to ureteral obstruc- Exciting clinical trials with novel chemotherapy agents
tion of calcium. A more destructive osteoclastic process tion) in patients suspected of having locally advanced and prostate cancer vaccines are under way as the sur-
(osteolytic metastases) occurs in 2% of cases. The disease. Immunoscintigraphy can also be used to reveal vival rate for hormone-refractory, metastatic prostate
pathologic fracture rate from prostate cancer is rela- extraprostatic disease, but these scans frequently yield cancer is grim and projected at 8% to 10% at 5 years.
tively low compared to that of other metastatic cancers
precisely because it induces bone-forming osteoblastic
reactions. Even when fractures occur, they heal simi-
larly to those of normal bone, limiting the need for
surgical stabilization. Elevation of the serum acid phos-
phatase level is found in two-thirds of patients with
metastases and is usually elevated when osteoblastic
metastases are present.

The value of a nuclear bone scan to detect bony
metastases is limited to patients with a Gleason sum
score lower than 7 and a prostate-specific antigen level
lower than 20 ng/mL. A bone scan is also indicated in
patients with prostate cancer who have symptoms sug-
gesting bony metastases, but bone scan activity may not

86 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 4-12 The Seminal Vesicles and Prostate

CARCINOMA OF PROSTATE III:
DIAGNOSIS, TREATMENT,
AND PALLIATION

Although many prostate cancers are palpable as nodules, Early carcinoma palpation rectally
because they are felt through the rectal wall, false- TRUS biopsy
positive diagnoses are possible. Therefore, transrectal
ultrasound (TRUS)–guided prostate biopsy is the stan- Urethra
dard for the diagnosis of prostate cancer. Classic zonal Prostate
anatomy (see Plate 4-1) is not evident on TRUS, but Biopsy needle
the peripheral zone, the source of most cancers, is dis- Ultrasound probe
tinguishable from the transition zone. Hypoechoic foci
on gray-scale TRUS are suggestive of cancer, but most Rectum
cancers are not visible on imaging. Therefore, system-
atic biopsy strategies have been developed to optimize Advanced carcinoma
cancer detection with TRUS imaging. before treatment

Transrectal ultrasound biopsies are performed with Various responses
a cleansing enema and antibiotic prophylaxis as the to hormone therapy
biopsy needle penetrates the rectal wall to enter the
prostate. Using sagittal and transverse imaging, pros- surgical extirpation in well-selected cases. Novel, high- Tumor palliation in cases of locally advanced or meta-
tate volume is assessed, followed by the determination dose-rate brachytherapy with 192iridium gamma radia- static cancer with androgen deprivation may also be
of gland contour, lesions, calcifications, and cysts. tion without seed placement is also common. Unique considered in select patients. The basis for the 1966
Under local anesthesia and sagittal imaging, an 18 G complications of radiation therapy for prostate cancer Nobel Prize in Medicine, the response of prostate cancer
spring-driven, needle core biopsy “gun” is passed include lower urinary tract symptoms, urinary reten- to androgen ablation is among the most reproducible
through a needle guide on the probe and sequential tion, radiation cystitis and proctitis, and the later devel- and profound of any therapy for a solid tumor. Certain
prostate biopsies are taken. Historically, biopsies were opment of erectile dysfunction. histologic changes occur in the cancer with a response
directed at palpable nodules and hypoechoic lesions. to hormonal treatment. The cytoplasm of the cells may
However, systematic biopsy schemes, beginning with In view of the fact that prostate cancer is slow growing become vacuolated, cell membranes may rupture, and
sextant biopsies (three biopsies/side), have replaced this and affects older men, and because prostate-specific cell borders can become indistinct, leaving pyknotic
approach. Currently, 10 to 16 biopsies are most com- antigen is an excellent marker of cancer progression, nuclei within a fibrous stroma. However, malignant
monly taken; in some centers, “saturation biopsies” many cases of localized cancer are treated with “expectant tissue never disappears completely and eventually
with up to 30 samples are taken when the clinical sus- management” or “watchful waiting”: observation until becomes a new disease: androgen-independent prostate
picion for cancer is extremely high. In patients without disease progression. For men whose life expectancy is <5 cancer. Administered through orchiectomy, antiandro-
access to the rectum, ultrasound-guided, transperineal years, few will die of the disease. This popular “treatment” gens, GnRH agonists, or androgen synthesis inhibitors,
prostate biopsies are routinely performed. Complica- option limits the morbidity of curative treatments that the median survival of patients with metastatic prostate
tions from TRUS prostate biopsies are unusual and may decrease quality of life in patients in whom disease cancer after therapy ranges from 28 to 35 months.
include urinary tract infections, sepsis, or more com- progression is unlikely or who will die of other causes.
monly rectal bleeding (hematochezia), hematuria, and
clot retention. Rectal bleeding is controlled with direct
pressure by digital exam, the ultrasound probe, or by a
rectal Foley catheter with the balloon inflated. Hema-
tospermia occurs in up to 50% of men after biopsy.

The clinical course of newly diagnosed prostate
cancer is difficult to predict. For every six patients diag-
nosed with prostate cancer, only one will die of the
disease. Today’s challenge is to identify those men with
aggressive, localized cancer with a natural history that
can be altered by definitive local therapy. For organ-
confined cancers, definitive or curative local therapy
consists of surgical extirpation (see Plates 4-18 to 4-20)
or irradiation.

Radiation therapy has been given for decades and has
undergone a significant evolution. To increase target
accuracy and reduce adverse effects from dosing to
surrounding tissues, conformal external beam radiation
of up to 78 to 79 Gy is guided by three-dimensional
imaging. Intensity modulation radiation therapy is
another advance that is based on inverse treatment plan-
ning that gives equal attention to reducing radiation to
surrounding tissues, and it modulates beam intensity
depending on individual anatomy. Heavy particle beam
therapy using protons and neutrons may offer further
protection for surrounding tissues. Described in the
1920s, brachytherapy (brachy = “close”) is the place-
ment of radioactive seeds into or near prostate tumors
for definitive cancer treatment. Typically performed
transperineally with TRUS guidance, seed placement
with brachytherapy uses 125iodine or 103palladium and is
an outpatient procedure with success rates that approach

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 87

Plate 4-13 Reproductive System

SARCOMA OF PROSTATE

Sarcoma of the prostate is a rare cancer (<0.1% of Spindle cell sarcoma Leiomyosarcoma Sarcoma of prostate
prostate malignancies), with most cases occurring in the with myxomatous (rhabdomyosarcoma)
first decade of life. Patients present with symptoms of changes
urinary obstruction or hematuria, and there can be Early leiomyosarcoma of prostate
associated bowel symptoms of constipation, inability to Sarcoma may be suspected on rectal examination,
defecate, or bloody stools. Sources of mesodermal as the prostate is usually replaced by a rubbery mass Rhabdomyosarcoma Lymphosarcoma
tissue giving rise to sarcoma are connective tissue, stri- that can be felt on rectal examination. The diagnosis disease at diagnosis is a uniformly poor prognostic
ated and smooth muscle, and lymphatic or vascular is established by either transrectal ultrasound–guided marker.
structures. Although many cases remain unclassified, prostate biopsy (see Plate 4-12) or by transurethral
for practical purposes prostatic sarcomas may be resection. The histologic type of prostate sarcoma The treatment of sarcoma of the prostate involves
grouped into the following categories. has prognostic significance, as pediatric patients mainly surgical extirpation. In the rare instance of early
with rhabdomyosarcoma do better than those with detection in which the disease is still confined to the
Myosarcomas arise from either smooth or striated other histologies, with a median survival of more adult prostate, a radical prostatectomy is indicated. In
muscle elements and comprise 50% to 60% of cases. than 10 years. Tumor grade and tumor size are the infant, it is necessary to remove the prostate,
Leiomyosarcomas are composed of interlacing bundles less relevant to outcome. The presence of metastatic seminal vesicles, and bladder with diversion of the
of malignant smooth muscle cells. Rhabdomyosarco- urinary stream. Multimodality therapy involving che-
mas generally present in childhood (mean age 5 years) motherapy and radiation therapy shows improved out-
and show cross and longitudinal striations within the comes over surgery alone with most sarcomas.
cytoplasm of striated muscle cells. They may exhibit
extreme pleomorphism in which spindle cells, round
cells, and bizarre multinucleated giant cells intermix.
These tumors typically grow to a large size, projecting
into the bladder as a large nodular mass.

Malignant fibrous histiocytoma (MFH) occurs in
10% to 15% of cases and is highly anaplastic, with
marked pleomorphism. MFH is really more of a
morphologic pattern rather than a distinct pathologic
entity. It is a synonym for undifferentiated, pleomorphic
sarcomas showing no specific line of differentiation.
Tumors in this group include storiform, angiomatoid,
myxoid, inflammatory, and giant cell sarcomas. A subset
of pleomorphic MFH tumors includes sarcomas that
are termed unclassified as they resemble one or more of
the above histologic types.

Lymphosarcomas constitute 5% of prostatic sarcoma
cases and originate from the sparse lymphatics within
the prostate. They contain mature and immature lym-
phocytes that obscure the architecture and show a ten-
dency to form lymphoid follicles. Lymphomatous
involvement of the prostate may also occur as a meta-
static manifestation of leukemia, Hodgkin disease, or
lymphosarcoma originating elsewhere in the body.

Carcinosarcoma of the prostate is rare and generally
occurs in men previously treated with androgen depri-
vation or radiation therapy for adenocarcinoma of the
prostate. It is a tumor that contains mixed elements of
adenocarcinoma and sarcoma and is very aggressive,
with a 5-year survival of <50%. Fibrosarcomas, origi-
nating from fibrous tissue and collagen, are most com-
monly found in soft tissue of the extremities and bone
but can be found in the prostate. These include both
spindle cell and round cell sarcomas, in which myxo-
matous degeneration may be present.

Sarcomas of the prostate can invade the bladder wall,
seminal vesicles, and rectum, with obstruction to the
bladder outlet and terminal ureters. Symptoms in the
adult are similar to those associated with benign prostatic
obstruction but progress within weeks or months to stran-
guria (straining to urinate). In the infant, symptoms may
mimic those of congenital urethral valves or obstructive
ureterocele. If urinary tract infection is superimposed on
obstruction, the symptoms may be accompanied by
dysuria, frequency, and hematuria. Regional spread to
surrounding tissues is a constant feature, with metastases
to neighboring lymph nodes, abdominal viscera, and bone
occurring fairly early. Pain is not a characteristic early
symptom but may be a salient feature after the tumor has
grown in size. Unlike prostatic carcinoma, sarcomas do
not cause an elevation of the serum acid phosphatase.

88 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 4-14 The Seminal Vesicles and Prostate

BENIGN PROSTATE SURGERY I—
SUPRAPUBIC

Assuming that observation and medical management Approach Incision
of benign prostatic hyperplasia (BPH) are not appropri-
ate or have failed (see Plate 4-9), surgical treatment is Peritoneum
indicated. For patients with acute urinary retention, Opening of
recurrent or persistent UTIs, recurrent gross hematu- bladder
ria, or bladder calculi, surgical management is also indi-
cated for BPH. The presence of prostate cancer should Enucleation
be excluded. Two general approaches to prostatectomy Closure of bladder
are endoscopic or open (incisional). Among open pro-
cedures, suprapubic and retropubic prostatectomy are Advancing the bladder mucosa into the prostatic fossa bladder, along with a Foley catheter to allow for con-
the most common. If the prostate gland is more than with absorbable suture at the 5- and 7-o’clock positions tinuous bladder irrigation. A perivesical, pelvic drain
75 g in weight or if suitable landmarks to guide endo- may also help with hemorrhage and possibly prevent may also be placed. The rectus muscles, fasciae, and
scopic surgery at not visible, then open prostatectomy subsequent bladder neck contracture. Pronounced skin are then reapproximated. The urethral catheter is
should be considered. hemorrhage despite these maneuvers is handled by removed after 2 to 4 days and a voiding trial adminis-
placement of a purse-string suture of heavy nylon tered by clamping the suprapubic tube. The postvoid
Suprapubic or transvesical prostatectomy, first per- around the bladder neck, passed out through the skin residual urine is checked with the suprapubic tube over
formed in 1894, requires few specialized instruments and tied firmly, as described by Malamet. With exces- several days, and this tube is removed if voiding is
and involves enucleation of the prostatic adenoma sive bleeding, a suprapubic catheter is also left in the adequate. Full activity is allowed after one month.
through an extraperitoneal, lower abdominal incision.
Compared with endoscopic approaches, open prosta-
tectomy offers a lower retreatment rate, a more com-
plete removal of the adenoma, and avoids the risk of
dilutional hyponatremia with transurethral resection
techniques. However, open prostatectomy involves a
midline incision and a longer hospitalization and con-
valescence period. In addition, there is more potential
for significant postoperative hemorrhage.

The open suprapubic approach is particularly well
suited to handle intravesical median lobe hypertrophy
and lateral lobe enlargement that has grown to the
point of projecting into the bladder. In addition, bladder
pathology, including calculi, diverticula, tumors, or
foreign bodies, can be treated simultaneously. Its chief
disadvantages are that it is a relatively involved trans-
abdominal and transvesical procedure that may not be
applicable to debilitated patients.

In this approach, the skin is opened through either a
lower midline or a transverse incision. The anterior
rectus sheath is divided either vertically or transversely,
and the rectus muscles are retracted laterally. This
allows visualization of the anterior bladder wall within
the space of Retzius, inferior to the peritoneal reflection
and above the symphysis pubis. The bladder is opened
with care to not expose any more of the prevesical or
paravesical space than necessary. Using electrocautery,
an incision is made in the bladder mucosa around
the bladder neck. Using scissors or a forefinger, the
cleavage plane is developed between the hyperplastic
adenoma and the compressed normal prostatic lying
against the true capsule of the prostate. With lateral
lobe hyperplasia, the finger is swept around the lateral
aspect of each lobe, including the anterior and posterior
commissures. The adenoma is brought into the bladder
through the bladder neck with care, and the paired
posterior prostatic arteries inspected for bleeding. If a
simple median lobe is present, the mucosa of the
bladder neck is incised on only its posterior surface, and
the line of cleavage developed between the hyperplastic
median lobe and the prostatic capsule. The operation
is usually performed blindly, as illustrated.

Following removal of the adenoma from within the
prostatic capsule, bleeding is usually controlled first by
packing the enucleated fossa with hemostatic gauze, and
then by fulguration or ligation of the prostatic arteries
near the bladder neck. Inflation of the Foley catheter
balloon within the fossa can also tamponade bleeding.

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 89

Plate 4-15 Reproductive System

Incision

BENIGN PROSTATE SURGERY II— Approach
RETROPUBIC

In general, urologists develop an aptitude for one type Exposure (incision
of prostatectomy and may favor this method. However, of prostatic capsule)
no single operative approach is applicable to all cases,
so most urologists select the operation that is most Enucleation
suitable to a given case. For surgical treatment of
benign prostatic hyperplasia (BPH), an open prostatec- Suture of capsule with Foley balloon inside
tomy technique developed in 1945 is the retropubic
approach, which in reality is a variation of the suprapu- Foley balloon
bic approach.
with a drain to the space of Retzius. The urethral cath- approach. Because of this, complete enucleation of the
Unlike the suprapubic approach (see Plate 4-14) in eter may be removed after 4 to 7 days. adenoma and precise transection of the urethra are pos-
which the bladder is entered, the retropubic prostatec- sible, lowering the recurrence rate and aiding the return
tomy involves directly incising the anterior prostatic The retropubic approach has slightly lower morbid- of continence. Secondary hemorrhage is uncommon,
capsule instead. Retropubic prostatectomy is techni- ity and a faster recovery than the suprapubic procedure and the urine clears relatively rapidly after the retropu-
cally more difficult than the suprapubic approach and because the bladder is not entered. Opening the bladder bic procedure. Again, because this is an “open” proce-
requires more retraction in a deeper wound. This is associated with more discomfort, dysuria, frequency, dure, the retropubic prostatectomy may not be indicated
approach is suitable for large prostates in which the and urgency postoperatively than if it is avoided. Excel- for severely debilitated patients, as it is associated with
hyperplasia involves mainly the lateral lobes and not lent anatomic exposure of the prostate is afforded by a low (<1%) but measurable mortality rate.
median lobe extension into the bladder. If an individual the retropubic approach, unlike with the suprapubic
is obese, retropubic exposure may be more difficult. If
bladder pathology coexists (tumors or stones) the ret-
ropubic approach is less desirable, because visualization
of the bladder cavity is difficult. It is also not recom-
mended for small glands or for prostate cancer.

The surgical approach through the skin and rectus
muscles to the prevesical space of Retzius is similar to
that of the suprapubic procedure. However, instead of
entering the bladder, the anterior surface of the pros-
tatic capsule beneath the symphysis pubis is exposed. It
may be necessary to divide the puboprostatic ligaments
while removing the areolar tissue from the anterior
surface of the prostate. The prostatic capsule is easily
identified by the overlying plexus of Santorini (see Plate
2-6), as these veins arborize over the surface of the
prostatic capsule. After ligating these veins, a transverse
(or vertical) incision is made into the prostatic capsule,
exposing the adenoma. Using the tip of the index finger,
a cleavage plane is easily developed between the
adenoma and the surgical (false) capsule (see Plate 4-7)
formed by the compressed normal prostatic tissue.
Further access can be obtained by insertion of a finger
from the other hand into the rectum to elevate the
prostate. The adenoma is shelled from the capsule and
brought up through the prostatic incision, where it is
then peeled and freed from the bladder neck. If the
bladder neck is small, a wedge of tissue is removed and
the bladder mucosa advanced into the prostatic fossa so
that a secondary bladder neck contracture does not
develop later.

Visualization of the prostatic fossa following removal
of the adenoma allows control of bleeding under direct
vision. To aid hemostasis, a Foley catheter is inserted
per urethra and the balloon inflated in the prostatic
fossa. The prostatic capsule is then tightly closed with
a continuous absorbable suture without the need for a
suprapubic catheter. Closure of the lower abdominal
wound is the same as with the suprapubic prostatectomy

90 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 4-16 The Seminal Vesicles and Prostate

BENIGN PROSTATE SURGERY III— Incision
PERINEAL

The perineal prostatectomy is an uncommon approach Approach
for the surgical treatment of benign prostatic hyperpla-
sia (BPH) but has several advantages over other “open” Exposure (transverse
approaches. The operation is excellent for the removal incision in capsule)
of very large glands and permits complete removal of
all adenomatous tissue. Anatomically, the perineal Enucleation (Young
region varies less dramatically with body habitus than retractor in place)
does the lower abdominal region, reducing operative
times. Patients with prior renal transplantation or mesh Foley balloon
inguinal hernia repairs in which the retropubic space
may be scarred or obliterated are particularly well Capsule and skin sutured Suture of capsule
suited for this approach. Drainage of fluid after the Foley balloon catheter in place
procedure is “dependent” in that infected urine or
exudate drains away from the operative area and is not leaves the bladder neck intact. After hemostasis is suture. A rubber Penrose drain is usually placed on one
retained within a cavity. Also, bleeding can be con- achieved in the prostatic fossa, a Foley catheter is side of the perineum and placed near the sutured pros-
trolled under direct vision. Finally, morbidity and con- inserted into the bladder and the balloon inflated within tatic capsule. The skin is closed with interrupted suture.
valescence are low and minimal, respectively, with the the fossa. As with other “open” surgical approaches, if Most capsules sutured in this manner will heal in 5 to
perineal approach. the adenoma is unusually large, excessive bleeding may 7 days, at which time the urethral catheter is removed.
occur. In such cases the bladder neck can be pulled Although not commonly used for the benign prostatic
On the other hand, the perineal prostatectomy is down and the prostatic capsular vessels can be ligated enlargement, the perineal approach is a well-established
technically more difficult than other open approaches, under direct vision. The prostatic capsule is then tightly and frequently used approach for the treatment of pros-
making an accurate knowledge of perineal structures closed with a continuous or interrupted absorbable tate cancer (radical perineal prostatectomy).
important to avoid injury to the rectal wall or external
sphincter muscle. In addition, the operation is not
suitable for extremely obese patients or those with
limited hip motion because of severe ankylosis of the
hip or spine or those with unstable artificial hips that
would limit the need for exaggerated lithotomy posi-
tioning required for the procedure. Common degen-
erative disc disease is not a contraindication for perineal
prostatectomy.

With the patient in high lithotomy position, a peri-
neal incision is made in the shape of an inverted “U”
with the apex 3 cm anterior to the anus. The ischiorec-
tal fossae on each side of the central tendon are opened
and developed bluntly with the index finger. The mus-
culofibrous central tendon is divided, exposing the
anterior rectal wall, which, with the rectal sphincter,
falls backward and away from the superficial transverse
perineal muscles. With gentle dorsal traction on the
rectum, the rectal wall is then detached from the pros-
tatic apex by dividing the rectourethralis muscle.
Caution is needed with this maneuver to avoid rectal
injury. The prostate is then delivered into the field
and further cephalad separation of the prostate from
the rectum is undertaken with blunt digital dissection
until the entire posterior surface of the prostate is
exposed, if necessary to beyond the ends of the seminal
vesicles.

After exposure of the posterior prostate, a transverse
incision is made across the center of the prostatic
capsule and into the prostatic urethra halfway between
the apex and base of the prostate. The incision in the
prostate in this location is made directly into the com-
pressed posterior zone tissue of prostate to expose the
adenoma. The lower lip of the incision through the
capsule is reflected backward, exposing the hyperplastic
adenoma and the urethral floor. A Young retractor is
inserted through the opening in the capsule, to provide
counterpressure that elevates the adenoma into the
wound. The index finger is then inserted into the cleav-
age plane between the adenoma and the surgical (false)
capsule and the two lateral lobes and any median lobe
are easily enucleated. Enucleation performed with care

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 91

Plate 4-17 Reproductive System

Monitor

BENIGN PROSTATE SURGERY IV— Transurethral approach
TRANSURETHRAL
Camera Light
Transurethral resection of the prostate (TURP) is cur- source
rently the most popular approach for the surgical treat-
ment of benign prostatic hyperplasia (BPH). It has the Irrigation Intravesical view
advantage of being an endoscopic procedure that avoids Cystoscope Lateral lobe encirclement
an abdominal or perineal incision and is associated with
earlier ambulation and faster convalescence than the Removal of
“open” approaches. It is appropriate for the treatment of median lobe
small to moderate size (<75 g) prostatic enlargement and
is technically more sophisticated than the open surgical Cystoscopic views
procedures. With benign prostatic enlargement, the
objective is complete removal of the adenomatous tissue 1 Lateral lobe BPH
to the surgical (false) capsule, but in cases of urethral 2 (before)
obstruction due to advanced prostatic cancer, a “channel” 4 37
TURP is performed to reestablish urethral patency.
58
The TURP was developed in the 1920s after the
invention of incandescent light, the cystoscope, and 69
high-frequency electrical current. It is considered
the standard for the surgical treatment of BPH. Classi- Lateral lobe resection
cally, transurethral prostatectomy employs a wire loop
through which a high-frequency current is used to cut Order of tissue removal After TURP
and coagulate tissue. The resectoscope is operated
entirely by one hand, leaving the other hand free for used as an irrigant and results from systemic absorption hyponatremic water. Methods that employ tissue vapor-
insertion of a finger into the rectum to elevate the pros- of water as a consequence of prolonged (1.5 hours) ization (TUVP) and desiccation, as well as laser-induced
tate. With the patient in lithotomy position, the penile resection time, resection of large glands, or early pen- destruction of tissue (Nd : YAG, KTP, holmium, and
urethra is calibrated with a bougie á boule to ensure that etration of the surgical prostatic capsule. The syndrome diode), in lieu of fulguration have also been developed
it is sufficient in size to accept a large cystoscope. If is characterized by confusion, nausea, vomiting, hyper- to reduce hematuria and catheterization time. Many
it is not, the cystoscope can be inserted through a peri- tension, bradycardia, and visual disturbance and can be minimally invasive methods of treating BPH have also
neal urethrostomy into the more commodious bulbar lethal if not carefully treated with 3% saline solution been described that may reduce the adverse effects of
urethra. To reduce back strain on the surgeon, a video and diuresis. TURP but do not appear to offer the same quality or
camera is commonly used to visualize the procedure. durability. These include intraprostatic stents, transure-
Recent variations on the classic TURP include the thral needle ablation of the prostate using radiofre-
Adenoma resection should be performed in a step- use of bipolar instead of monopolar electrocautery quency energy, and transurethral microwave therapy.
wise, orderly fashion and typically begins at the bladder that can be used with saline irrigation instead of
neck as described by Nesbitt. The adenoma is resected
at the bladder neck around its circumference until the
circular fibers of this structure are visible. Many sur-
geons also resect the intravesical median lobe at this
point (as illustrated), to increase irrigant flow and
overall visibility for the remainder of the procedure.
Next, one of the lateral lobes is chosen for resection.
The resectoscope is placed immediately proximal to the
verumontanum to minimize damage to the external
urethral sphincter and tissue resection starts at the
12-o’clock position to allow the remaining lateral lobe
tissue to “fall into” the prostatic fossa. With each excur-
sion of the cutting loop, a “boat-shaped” piece of ade-
nomatous tissue is cut away and allowed to fall into the
bladder. Bleeding is controlled by application of a
hemostatic current through the wire cautery loop.
Resection proceeds to the 6-o’clock position and is
carried down to the false or surgical capsule, which
appears more fibrous than the granular adenoma. The
other lateral lobe is then similarly approached. The
final part of the procedure involves careful tissue
removal from the floor of the prostate and from the
prostatic apex near the external sphincter while preserv-
ing the verumontanum. At the end of the procedure,
accumulated tissue in the bladder is aspirated through
the sheath of the instrument, followed by the insertion
of a Foley catheter. The catheter remains in place for
24 to 48 h and obstructing blood clots are minimized
with continuous bladder irrigation if needed.

Sequelae of TURP include bleeding requiring trans-
fusion or reoperation, urethral or bladder neck stric-
tures, retrograde ejaculation, incontinence, and erectile
dysfunction. Dilutional hyponatremia (TURP syn-
drome) occurs in 2% of cases when isotonic water is

92 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 4-18 The Seminal Vesicles and Prostate

MALIGNANT PROSTATE Cross section through urethra
SURGERY I—RETROPUBIC Deep dorsal vein
Striated urethral sphincter
Prostate cancer is the second leading cause of death Urethra
from cancer in U.S. men. The definitive treatment of Neurovascular bundle
clinically localized prostate cancer with radical retropu-
bic prostatectomy has been a popular treatment for 100 Seminal vesicle Incision
years. Although a technically formidable procedure, it Bladder
remains the “gold standard,” as hormone treatment and Rectum Urethra
chemotherapy are not curative and radiation therapy Neurovascular bundle
may not eradicate all cancer cells. The advantage of Prostate Neurovascular
radical prostatectomy is that it offers cure with minimal Deep dorsal bundle
collateral damage, provides more accurate pathologic venous complex Prostate
staging, and treatment failure is easily identified. The Urethra
ideal candidate for the procedure is healthy, less than
75 years old, has a life expectancy of at least 10 years, Prostatic apex exposure
and has a biologically “significant” tumor.
Prostate
Radical retropubic prostatectomy involves the com- Bladder
plete removal of the prostate gland and seminal vesicles
and may include a pelvic lymph node dissection. The Urethra
goals of surgery are cancer control and preservation of
urinary control and sexual function. A spinal, epidural, or Division of bladder neck
general anesthetic is generally used with the patient in
the supine or relaxed dorsal lithotomy position. A Neuro-
midline, extraperitoneal lower abdominal incision from vascular
the pubis halfway to the umbilicus is made after a Foley bundle
catheter is placed in the bladder. The rectus muscles are
separated in the midline, the transversalis fascia opened Bladder
sharply, and the space of Retzius developed. Laterally,
the peritoneum is mobilized off of the external iliac Reconstruction of bladder and urethra
vessels (see Plate 2-6) to the bifurcation of the common
iliac artery. A self-retaining Balfour retractor is then superiorly. Denonvilliers fascia is included with the free, staying close to these organs to avoid damage to
placed, and a narrow malleable blade provides excellent prostate. In nerve-sparing procedures, the levator fascia the pelvic plexus laterally. After the specimen is removed,
exposure for lymph node dissection. The lymph node is incised on the lateral prostate but the prostatic fascia the operative site is inspected for bleeding and residual
dissection, if done, is first undertaken on the side ipsilat- must be left intact during the superior dissection, as the tumor. The bladder opening is closed with absorbable
eral to the prostate tumor and proceeds by dividing the neurovascular bundle is located between the levator suture in a “tennis racket” manner to a diameter that
tissue over the external iliac vein. The lymphatic tissue is fascia and prostatic fascia. approximates the urethra, and a rosette of mucosa is
excised to the lateral pelvic wall, inferiorly to the femoral created to line the bladder neck opening for a better
canal, and superiorly to the bifurcation of the common For the remainder of the posterior dissection, the anastomotic seal. Finally the bladder neck is sutured to
iliac artery. The obturator lymph nodes are also removed Foley catheter is replaced. After the prostate has been the distal urethra using the preplaced sutures, a new
by skeletonizing the obturator vein and artery and mobilized completely, the bladder neck is incised com- Foley catheter is placed, and the incision closed. The
sparing the obturator nerve. Frozen section is then per- pletely at the prostatovesicular junction. After the pos- patient is allowed to ambulate the day after the proce-
formed on the excised nodes before prostatectomy. terior bladder wall is divided, the bladder neck is dure and is discharged on hospital day 1 or 2. Excellent
retracted and the medially located vasa deferentia are cancer control is achieved with this operation.
Exposure for retropubic prostatectomy involves dis- ligated. The paired seminal vesicles are then dissected
placing the peritoneum superiorly and removing the
fibroadipose tissue covering the anterior prostate. These
maneuvers expose the pelvic fascia, puboprostatic liga-
ments, and superficial dorsal vein. The endopelvic fascia
is then entered where it reflects over the pelvic side wall,
allowing palpation of the lateral prostate. By finger dis-
section, the levator ani muscles are released from the
lateral prostate and, with sharp dissection, the pubopros-
tatic ligaments are taken down anteriorly. The dorsal
vein complex is then ligated with care to avoid damage
to the striated urethral sphincter. These maneuvers help
to optimally expose the prostatic apex for dissection.

The apical dissection is the most complex and critical
step in the operation, as the striated urethral sphincter
and the neurovascular bundles that control erections
are nearby and the prostatic apex is the most common
site for positive surgical margins. With gentle posterior
displacement of the prostate, the prostatourethral junc-
tion is visualized. A right angle clamp is passed around
the smooth muscle of the urethra anterior to the
neurovascular bundles near the prostatic apex and the
urethra is transected sharply. Six interrupted absorbable
sutures are then placed in the distal urethra while the
exposure is optimized and the Foley catheter is removed.
The posterior aspect of the prostate is now exposed,
allowing its dissection off the anterior rectal wall

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 93

Plate 4-19 Reproductive System
Central tendon (cut)
MALIGNANT PROSTATE
SURGERY I—PERINEAL

The radical perineal prostatectomy was first described Exaggerated lithotomy position Denonvilliers
as a surgical cure for prostate cancer in 1905. Its popu- fascia over
larity waned in the late 1970s as the importance of the prostate
pelvic lymph node dissection for accurate staging was
elucidated. More recently, there has been renewed Rectourethralis
interest in this anatomic approach to prostate cancer as muscle
more accurate staging methods have reduced the need
for staging lymph node dissection. In addition, similar External
to its advantages in benign prostate surgery (see Plate sphincter
4-16), the perineal approach for prostate cancer treat- ani muscle
ment offers unmatched visualization of the apical pros-
tate and urethral dissection, is important for cancer Levator ani muscle
cure, and is associated with less blood loss. Unlike with
the retropubic approach, a full bowel preparation is Central tendon (cut)
given the day before perineal surgery. After the induc-
tion of anesthesia, the patient is placed in an exaggerated Perineal anatomy
lithotomy position; severe hip ankylosis or unstable
prosthetic hips may thus be a contraindication to this Incision Rectourethralis muscle
approach. A curved Lowsley retractor is placed trans- (cut)
urethrally into the bladder and its wings opened. A Denonvilliers fascia
curvilinear incision is made around the anus as described Neurovascular bundle
for the perineal prostatectomy for benign prostatic Rectum
hyperplasia (BPH; see Plate 4-16). After bluntly devel-
oping the ischiorectal fossa on each side, the central Incision of Denonvilliers fascia
tendon is cut and the longitudinal muscle fibers of the
rectum identified. With gentle traction on the rectum, Urethra Urethra
dissection is carried superiorly until the rectourethralis Prostate
muscle, which connects the rectum to the perineal body, Neurovascular
is identified. The rectourethralis muscle is divided close bundle
to the prostatic apex, allowing the rectum to fall dor-
sally. The risk of rectal injury is highest at this point. Bladder
Ideally, this dissection is between the leaves of Denon-
villiers fascia. With pressure on the Lowsley retractor, Incising urethra Reconstruction of bladder and urethra
the prostate is delivered into the field, allowing blunt,
digital dissection of the prostate until its base is identi- reconstruct the bladder neck in a “tennis racket” fashion advised to ambulate the evening of surgery, and the
fied at the vesicoprostatic junction. with absorbable suture. Accurate anastomotic suture drain is removed and patients are advanced to a regular
placement between the bladder neck and membranous diet the day after surgery. Rectal stimulation and
Unlike with perineal prostatectomy for BPH, the pro- urethra is guided by better visualization of these struc- medications are prohibited. Hospital discharge is on
static capsule is not incised when the entire gland is to be tures with the perineal method compared to the retro- day 1 or 2 after surgery. Unique but infrequent com-
removed. Instead, the exposed anterior layer of Denon- pubic approach. A Penrose drain is placed near the plications of the perineal prostatectomy are transient
villiers fascia is incised vertically in the midline from the bladder neck anastomosis and brought out through the lower extremity sensory neurapraxia (<2%), and rectal
base to the apex of the prostate to preserve the neurovas- skin incision. The levator ani muscles and central incontinence (<3%). Rates of urinary incontinence
cular bundles. Careful lateral dissection and gentle trac- tendon are then reapproximated, and the skin closed and erectile dysfunction are comparable to those of
tion help to preserve the neurovascular bundles as they with interrupted vertical mattress sutures. Patients are retropubic methods.
course between the leaves of Denonvilliers fascia. At the
prostatic apex, the bundles are also dissected free of the
urethra, and the posterior urethra is incised sharply
over the Lowsley retractor. With traction on the retrac-
tor, the anterior urethra is then transected and the pros-
tate freed to the bladder neck by sharp and blunt
dissection. The puboprostatic ligaments are then tran-
sected. Care is needed to avoid injuring the dorsal venous
complex during this dissection of the anterior prostate.

The prostate–bladder neck junction is identified by
palpation of the wings of the Lowsley retractor. With
sharp and blunt dissection, the bladder neck is preserved.
The bladder neck is first incised anteriorly to avoid
injury to the ureteral orifices posteriorly. With traction
on the prostate, the bladder neck incision is continued
circumferentially around the prostate base, dissecting
and ligating the lateral pedicles coursing toward the
prostate. Ligation of these pedicles is performed close
to the prostate to avoid injury to the adjacent neurovas-
cular bundles. With further posterior dissection, the
paired vasa deferentia are ligated and transected and the
seminal vesicles are excised with the prostate.

After the specimen is removed, the bladder neck is
easily visible. Occasionally, it may be necessary to

94 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 4-20 The Seminal Vesicles and Prostate

MALIGNANT PROSTATE Laparoscopic radical Robotic radical
SURGERY I—LAPAROSCOPIC prostatectomy prostatectomy
AND ROBOTIC
Periumbilical trocar Monitor
In an effort to decrease the morbidity associated with Perirectus trocar
radical prostatectomy surgery, minimally invasive, lapa- Assistant Surgeon Robot
roscopic approaches to prostate removal have become slave
popular over the last 10 to 15 years. This is possible Assistant system
because of advances in task-specific surgical instru-
ments, digital video equipment, and computers and Monitor Surgeon
robotic technology. Robotic laparoscopic prostatec- console
tomy, introduced in 2002, incorporates “wristed tech-
nology” in robotic arms that enable movement with the Posterior antegrade dissection
facility of a human wrist. This advance promises to between bladder and rectum
reduce the longer operative times and learning curve
associated with laparoscopic prostatectomy. Long-term Posterior Anterior Seminal vesicle
cure rates with laparoscopic procedures are now being antegrade antegrade Vas deferens
reported and appear similar to those of retropubic and dissection dissection Bladder
perineal approaches.
Anterior antegrade dissection Denonvillier’s
The indications for laparoscopic or robotic prosta- of bladder and prostate fascia
tectomy are identical to those for open surgery. Contra-
indications include an uncorrectable bleeding diathesis Anterior puboprostatic ligament Rectum
or the inability to undergo general anesthesia. Prior Prevesical fat
lower abdominal surgery, morbid obesity, large prostate Deep dorsal
size, and prior pelvic irradiation or TURP (see Plate venous complex
4-17) are relative contraindications. Before the proce-
dure, a mechanical bowel preparation is given and the Prostate
patient must be aware of the potential for conversion
to open surgery. In addition, a highly trained surgical Bladder Neuro-
team skilled in laparoscopic techniques is critical. With Urachus vascular
the patient in the supine or low lithotomy position with bundle
steep Trendelenburg, nasogastric and urethral tubes are
placed to decompress the stomach and bladder. Bladder

The surgical principles for radical prostatectomy are Seminal vesicle
similar for pure laparoscopic and robotic approaches.
The surgical robot uses three working arms and a Vas deferens
remote surgeon console instead of a bedside surgeon
and assistants with pure laparoscopy. The surgeon in junction. The deep dorsal venous complex is then begun posteriorly, where the tension is the highest, and
the remote console has control of a three-dimensional ligated but not divided. In nerve-sparing procedures, an proceeds anteriorly using either an interrupted or
camera and all three robot arms and inserts thumbs and incision is made in the levator fascia on the anterolateral running closure. A Foley catheter is placed under vision
index fingers into master controls that allow natural prostate and a “groove” developed between the neuro- before the anastomosis is finished. A closed suction
wrist movements to be duplicated by the robot. In the vascular bundle and the prostate. The anterior bladder drain may be left in place in the prevesical space. Finally,
classic transperitoneal approach, a pneumoperitoneum neck is then divided, the ureteral orifices located, and the entrapment sac and specimen are delivered through
is established using a Veress needle at the base of the the prostatic pedicles controlled. The course of the an extension of the infraumbilical incision, and the fascia
umbilicus or an open Hasson trocar, and insufflation subsequent antegrade or descending dissection of the of this incision is closed primarily. The smaller trocar
pressure is maintained at 15 mm Hg. Secondary trocars neurovascular bundle is guided by the previously defined sites do not require fascial closure. Patients are generally
are placed under direct view, in both pararectus regions, lateral “groove” and proceeds as far distally as possible. discharged on hospital day 1 after laparoscopic prosta-
and halfway between the anterior–superior iliac crest tectomy. Operative times are typically longer with lapa-
and pararectus trocars on each side. Proximal to the previously placed ligature, the dorsal roscopic than open methods, ranging from 3 to 6 hours,
venous complex is divided and the prostatic apical dis- but postoperative pain rates are similar with both
Initially, the relevant pelvic landmarks visualized section completed. The anterior urethra is then divided approaches. Blood loss is generally less with laparo-
include the bladder, median umbilical ligament sharply, followed by division of the posterior urethra in scopic methods as the dorsal venous complex is divided
(urachus), the paired medial umbilical ligaments, vasa the fully mobilized prostate specimen. The specimen later in the course of surgery, and the pneumoperito-
deferentia, iliac vessels, and rectum. The peritoneum is put in an entrapment sac and placed in the right neum has a tamponading effect on venous bleeding.
overlying the vas deferens is incised and the vas deferens lower quadrant. The vesicourethral anastomosis is then
divided and traced distally toward the seminal vesicles.
The seminal vesicles are carefully dissected free using
surgical clips in lieu of cautery to avoid injury to nearby
neurovascular bundles. With anterior displacement of
the seminal vesicles, a small incision is made in Denon-
villiers fascia. Using blunt dissection, the plane between
the prostate and rectum is developed, a maneuver criti-
cal to minimizing the risk of rectal injury later.

Next, the bladder is dissected from the anterior
abdominal wall after dividing the urachus, and the space
of Retzius developed. The anterior prostate is defatted
and the endopelvic fascia and puboprostatic ligaments
are divided, exposing the levator ani muscle fibers on the
lateral prostate. These fibers are carefully dissected
from the prostate surface, exposing the prostatourethral

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 95

Plate 4-21 Reproductive System

SEMINAL VESICLE Retrovesicle Transvesicle approach
SURGICAL APPROACHES Transvesicle

Trans- Paravesicle
coccygeal
The seminal vesicle is a uniquely male organ, derived
from the mesonephric duct (see Plate 1-2) beginning at Transperineal Bladder
13 fetal weeks. The normal adult seminal vesicle is 5 to Transcoccygeal approach Trigone
8 cm in length and 1.5 cm in width and has a volume of Opening
10 mL. The blood supply is derived from the deferential Vas deferens of ureter
artery or, occasionally, from branches of the inferior Seminal vesicle
vesical artery. The seminal vesicles receive innervation Vas deferens
from adrenergic fibers via the hypogastric nerve. Seminal
vesicle
Primary pathologic states of the organ are rare.
Congenital lesions include ureteral ectopy, cysts, and Rectum
aplasia, many of which can be observed. Infections of Prostate
the seminal vesicles are uncommon, but tuberculosis
and schistosomiasis can cause masses, abscesses, and Retrovesicle approach
calcifications. Primary benign tumors include papillary
adenoma, cystadenoma, fibroma, and leiomyoma. Rectum
Malignant neoplasms are extremely rare and include
papillary adenocarcinoma and sarcoma. Radical excision Denonvillier’s
of the organ is the standard treatment for malignancy. fascia
Far more common than primary malignancy is second-
ary involvement from adenocarcinoma of the bladder, Bladder
prostate or rectum, and lymphoma. Few established
alternatives to surgery exist for seminal vesicle tumors. Rectum
Vas deferens
A variety of open surgical approaches to the seminal Seminal vesicle
vesicles have been described, including transvesical,
transperineal, paravesical, retrovesical, and transcoccy- Bladder
geal methods. In addition, a laparoscopic retrovesical
approach is rapidly gaining in popularity. The chosen The retrovesical approach is appropriate for bilateral the perineum or lower abdomen is not accessible
approach depends on the nature of the lesion to be seminal vesicle excision of small cysts or tumors. A because of limitations in patient positioning or due
excised and surgeon experience. midline, infraumbilical, intraperitoneal incision is made to multiple prior surgeries. With the patient in the
to gain access to the bladder dome and the cul-de-sac prone, jackknife position, an incision is made along the
Transvesical approach. With the patient supine, an between bladder and rectum. The small and large bowel coccyx and angled into a gluteal cleft. The coccyx is
infraumbilical, extraperitoneal incision is made, the are packed superiorly, and the peritoneal reflection near removed, and the gluteus maximus muscle retracted
rectus muscles separated, and the space of Retzius the posterior bladder is incised over the rectum. With laterally to expose the rectosigmoid colon. After
entered. A Balfour retractor exposes the anterior bladder sharp dissection, the bladder is peeled forward off the Denonvilliers fascia is incised deep to the rectum, it is
wall, which is then opened with a vertical incision. The rectum until the ampullae and the seminal vesicle apices dissected off the prostate with exposure of the seminal
retractor is repositioned within the bladder to expose the are visualized. In a manner similar to the paravesical vesicles. Injury to the neurovascular bundle is more
trigone and posterior bladder wall. With a cutting Bovie, approach, the seminal vesicles are dissected to the prosta- likely with this approach because it is directly in the
a vertical incision is made through the trigone near the tic base and the organ ligated. The retrovesical approach path of dissection. After the seminal vesicles are
bladder neck and the ampullae of the vasa deferentia are can also be performed laparoscopically (see Plate 4-20). removed, the rectum is carefully inspected for injury.
visualized posteriorly. The seminal vesicles are identi- The wound is closed in anatomic layers, and a drain is
fied lateral to the ampullae, dissected free, ligated, and Transcoccygeal approach. Less commonly used, placed.
divided. A metal clip placed across the cut end of the this dissection is appropriate for individuals in whom
seminal vesicle minimizes organ spillage. The distal vas-
cular pedicle is identified and controlled with clips or
ties, and the organ removed. Too deep a dissection risks
violating Denonvilliers fascia and entering the rectum.

Transperineal approach. This approach to seminal
vesiculectomy is virtually identical to that described for
radical perineal prostatectomy (see Plate 4-18). To
adequately expose the seminal vesicle, the rectum
should be dissected off the posterior prostate to a point
higher than that needed for perineal prostatectomy.
The vasal ampullae can be spared for the excision of a
simple seminal vesicle cyst or small tumor but may need
resection in the setting of cancer or infection.

Paravesical and retrovesical approaches. The
paravesical approach commences with an infraumbilical
incision to expose the space of Retzius, and the bladder
is bluntly dissected away from the pelvic side wall. The
vas deferens is tracked medially toward the bladder base
to help locate the seminal vesicle. The plane between
the bladder and seminal vesicle is developed from later-
ally to medially. As the seminal vesicle is dissected, the
awareness that the vas deferens crosses over the ureter
helps avoid ureteral injury. The bladder is rolled medi-
ally for better exposure. The neck of the seminal vesicle
is defined at the prostate base and the organ ligated with
absorbable suture.

96 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 4-22 The Seminal Vesicles and Prostate

ANOMALIES OF Adenomatoid tumor
THE SPERMATIC CORD of spermatic cord

Tumors of the paratesticular tissues and spermatic cord Atretic vas
are rare and can occur in all age groups. More often, deferens
paratesticular tissues are involved by extension from and absent
primary germ cell testis tumors. Benign tumors are cauda epididymis
observed in two of three cases and are usually mesoder-
mal in origin and include adenomatoid tumors, lipomas, Complete absence of
fibromas, occasionally myomas from the cremasteric vas deferens and of the
muscle, hemangiomas, neurofibromas, and lymphan- cauda and corpus epididymis
giomas. Adenomatoid tumors are the most common
benign tumors, accounting for 30% of all paratesticular Absence of entire left seminal tract
tumors. They present as solid, asymptomatic masses
found on routine examination and are located in the normal in 90% of men with CBAVD. It is thought that in mature, functional CFTR protein. It also appears that
epididymis, testis tunic, or, rarely, the spermatic cord. CBAVD is based on similar allelic patterns as that a coexisting 5T variant can turn an otherwise pheno-
On sectioning, they appear uniformly white, yellow, or observed in typical CF but it involves less-severe muta- typically mild CFTR mutation into a severe one.
tan and exhibit a fibrous consistency. Histologically, tions. Isolated CBAVD is considered an “atypical” form
epithelial cells with vacuoles and uniformly sized, round of CF and may be associated with subtle lung disease, To complicate matters further, patients with congeni-
nuclei are observed. Occasionally, adenomatoid tumors including chronic cough, sinusitis, and nasal polyps. tal unilateral absence of the vas deferens (CUAVD) are
are misclassified as mesotheliomas. Dermoid cysts, the another male infertility phenotype that is associated
term given to cysts lined by squamous epithelium, are In addition to CFTR gene mutations, another genetic with CFTR mutations. Clinically similar to CBAVD
also rare causes of scrotal masses. Mesotheliomas of the abnormality in CBAVD patients is variation in the patients, affected men have a palpable vas deferens on
testis adnexa usually present as firm, painless scrotal polythymidine tract of the splicing region of intron 8 one side. Despite this, many CUAVD patients have
masses in association with an enlarging hydrocele (see (IVS8), a noncoding DNA sequence within the CFTR azoospermia, suggesting the presence of additional,
Plate 3-9) in older individuals. Grossly, they are poorly gene. Three alleles have been detected in this region: occult wolffian duct abnormalities contralaterally.
demarcated lesions with firm, shaggy, and friable areas 5T, 7T, and 9T, and the efficiency of the splice acceptor Wolffian duct anomalies that are unrelated to CF gene
throughout. Microscopic examination reveals complex site function is greatest with the 9T allele. A reduction mutations can also result in CBAVD. These patients
papillary structures and dense fibroconnective tissue to 5T decreases the efficiency of splicing, leading to a have associated ipsilateral renal hypoplasia or agenesis
containing scattered calcifications. 10% to 50% reduction in CFTR mRNA and a decrease and generally do not demonstrate CFTR mutations.

Malignant paratesticular tumors are also rare and
include, in decreasing frequency, rhabdomyosarcoma
(40%), leiomyosarcoma, fibrosarcoma, liposarcoma,
and undifferentiated tumors. Patients generally present
with a growing scrotal mass that is solid and non-
transilluminating on palpation. These tumors must be
differentiated from spermatic cord cysts, hydroceles,
spermatoceles, varicoceles (see Plate 3-10), and hernias.
Most malignant tumors occur at the distal end of the
cord near the scrotum, whereas benign tumors are more
often encountered proximally toward the inguinal
canal. Primary malignant tumors of the epididymis are
exceedingly rare and mandate an evaluation for meta-
static adenocarcinoma. The treatment of benign lesions
is simple excision, whereas high inguinal orchiectomy,
followed by radiotherapy and chemotherapy, is stan-
dard treatment for malignant lesions.

Cystic fibrosis (CF) is the most common autosomal
recessive disease in Caucasians, with an incidence of
1 : 2500 births and a carrier frequency of 1 : 20. The CF
gene, called cystic fibrosis transmembrane regulator
gene (CFTR; 7q31.2), was cloned in 1989 and encodes
the cyclic adenosine monophosphate–regulated chloride
channel found in many secretory epithelia. More than
1500 mutations have been identified in the CFTR gene
to date. Clinical features of CF include chronic pulmo-
nary obstruction and infection, exocrine pancreatic insuf-
ficiency, neonatal meconium ileus, and male infertility.
Indeed, more than 95% of affected men have abnormali-
ties in wolffian duct–derived structures manifesting most
commonly as congenital bilateral absence of the vas def-
erens (CBAVD). Anatomically, the body and tail of the
epididymis, vas deferens, seminal vesicles, and ejaculatory
ducts may be absent or atretic, but the testis efferent ducts
and caput epididymis (see Plate 3-3) are always present.

Interestingly, 1% to 2% of otherwise healthy, infer-
tile men also have CBAVD, which is considered a
genital form of CF. These patients exhibit the same
spectrum of wolffian duct defects as those with CF but
lack the severe systemic problems. Spermatogenesis is

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SECTION 5

SPERM AND
EJACULATION

Plate 5-1 Reproductive System

ANATOMY OF A SPERM Spermatogonia A

The mature spermatozoon is an elaborate, specialized Spermatogenesis
cell produced in massive quantity, up to 1200 per
second. Spermatogenesis begins when Type B sper- Mitochondria Acrosome
matogonia divide mitotically to produce diploid primary Microtubules
spermatocytes (2n), which then duplicate their DNA Spermatogonia B Mitosis Centriole Flagellum
during interphase. After a meiotic division, each daugh-
ter cell contains one partner of the homologous chro- Sperm- Golgi
mosome pair, and they are called secondary spermatocytes atocyte I apparatus
(2n). These cells rapidly enter a second meiotic division
in which the chromatids then separate at the centromere Spermatocyte II Nucleus Spermiogenesis
to yield haploid early-round spermatids (n). Thus, theo- Spermatid
retically, each primary spermatocyte yields four sper- Meiosis I Spermatid
matids, although fewer actually result, as the complexity Sperm Meiosis II
of meiosis is associated with germ cell loss. Sperm

The process by which spermatids become mature Spermiogenesis
spermatozoa within the Sertoli cell takes several weeks
and consists of several events: the acrosome is formed Sperm (cross section) Mitochondria sheath Plasma membrane
from the Golgi apparatus; a flagellum is constructed Axial filament Nucleus
from the centriole; mitochondria reorganize around the Acrosome
midpiece; the nucleus is compacted to about 10% of its Side view
former size; and residual cell cytoplasm is eliminated.
With completion of spermatid elongation, the Sertoli Centriole
cell cytoplasm retracts around the developing sperm,
stripping it of unnecessary cytoplasm and extruding the Top view
sperm into the tubule lumen. The mature sperm has
remarkably little cytoplasm. End piece Principal piece Mid piece

The human spermatozoon is approximately 60 μm in Plasma membrane Tail Neck Head
length and is divided into three anatomic sections: head, Radial spoke Axonemal structure of sperm
neck, and tail. The oval sperm head, about 4.5 μm long
and 3 μm wide, consists of a nucleus containing highly Double microtubule
compacted chromatin, and an acrosome, a membrane-
bound organelle harboring the enzymes required for Inner dynein arm
penetration of the outer vestments of the egg before
fertilization. The sperm neck maintains the connection Outer dynein arm
between the sperm head and tail. It consists of the con-
necting piece and proximal centriole. The axonemal Central pair
complex extends from the proximal centriole through of singlet
the sperm tail. The tail harbors the midpiece, principal microtubules
piece, and endpiece. The midpiece is 7 to 8 μm long
and is the most proximal segment of the tail, terminat- Inner sheath Bridge
ing in the annulus. It contains the axoneme, which is
the 9 + 2 microtubule arrangement, and surrounding for oxidative phosphorylation: the NADPH dehydro- pattern of 9 outer doublets encircling an inner central
outer dense fibers. It also contains the mitochondrial genase, succinate dehydrogenase, cytochrome bc1, cyto- doublet. The protein dynein extends from one micro-
sheath helically arranged around the outer dense fibers. chrome c oxidase, and ATP synthase complexes. The tubule doublet to the adjacent doublet and forms both
The outer dense fibers, rich in disulfide bonds, are not sperm axoneme contains enzymes and structural pro- the inner and outer “arms” of the axoneme. Sperm with
contractile proteins but are thought to provide the teins necessary for the chemical transduction of ATP outer arm mutants have reduced motility and those
sperm tail with the elastic rigidity necessary for progres- into mechanical movement. The plasma membrane with inner arm mutants have no motility. Radial links
sive motility. Similar in structure to the midpiece, the covering the sperm-head region harbors specialized or spokes connect a microtubule of each doublet to the
principal piece has several columns of outer dense fibers proteins that participate in sperm–egg interaction. central inner doublet and consist of a complex of pro-
that are replaced by the fibrous sheath. The fibrous teins. Tektins are proteins associated with the outer
sheath consists of longitudinal columns and transverse The axoneme is the true motor assembly and requires microtubular doublets, and nexin links are proteins that
ribs. The sperm terminates in the endpiece, the most 200 to 300 proteins to function. Among these, the connect the outer doublets to each other and maintain
distal segment of sperm tail, which contains axonemal microtubules are the best-understood components. the cylindrical axonemal shape.
structures and the fibrous sheath. Except for the end- Sperm microtubules are arranged in the classic “9+2”
piece region, the spermatozoon is enveloped by a highly
specialized plasma membrane that regulates the trans-
membrane movement of ions and other molecules.

The spermatozoon is a remarkably complex meta-
bolic and genetic machine. The 75 mitochondria that
surround the axoneme contain enzymes required for
oxidative metabolism and produce adenosine triphos-
phate (ATP), the primary energy molecule for the cell.
Mitochondria are semiautonomous organelles that
produce cellular energy and can also cause apoptotic
cell death through the release of cytochrome c. Mito-
chondria are composed of double (outer and inner)
membranes. Five distinct respiratory chain complexes
span the width of the inner membrane and are necessary

100 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 5-2 Sperm and Ejaculation

SEMEN ANALYSIS AND
SPERM MORPHOLOGY

Although not a true measure of fertility, the semen Normal Sperm morphology
analysis, if abnormal, suggests that the probability of
achieving fertility is lower than normal. For a male Sperm viewed under microscope Bead
infertility evaluation, two semen analyses, performed Antibodies
with 2 to 3 days of sexual abstinence, are sought due to
the large biologic variability in semen quality. Lubri- Sperm
cants should be avoided and the specimen kept at body
temperature during transport. Sperm antisperm antibody test
(Immunobead method)
Normal values have been defined for the human
semen analysis by expert consensus (World Health Seminal leukocytes Evaluation of sperm chromosomes
Organization). Fresh semen is a coagulum that liquefies (FISH method)
from 5 to 30 min after ejaculation. After liquefaction, (IVF). In general, the percentage of sperm with normal
semen viscosity is measured and should not show any morphology has the greatest discriminatory power Other fertility assays can evaluate whether the seminal
stranding. Ejaculate volume should be at least 1.5 mL, among all descriptors of semen quality in distinguishing environment is abnormal, which may contribute to male
as smaller volumes may not sufficiently buffer against fertile from infertile semen, although no particular infertility. Two such tests include an evaluation for exces-
vaginal acidity. Although most commonly a conse- value is diagnostic of fertility. Sperm morphology sive semen leukocytes (leukocytospermia) and testing
quence of collection error, low ejaculate volume may can be altered by toxic and occupational exposures, for antisperm antibodies that can inhibit sperm transport
also indicate retrograde ejaculation, ejaculatory duct varicocele, fevers, medications, and systemic disease. through the female reproductive tract and impair sperm–
obstruction, or androgen deficiency. Sperm concentra- It appears that sperm morphology is a sensitive indica- egg interaction at fertilization. Sperm genetics can
tion should be >20 million sperm/mL. Reasons for low tor of overall testicular health, because the sperm also be directly assessed for chromosomal normalcy
sperm concentrations can include medications, expo- morphologic characteristics are determined during with in situ hybridization techniques. These tests can
sures, systemic disease, hormonal disorders, varicocele, spermatogenesis. complement the routine semen analysis in the male
unilateral blockage, and genetic syndromes. Sperm evaluation and better estimate the chances of fertility.
motility is assessed in two ways: the proportion of all
sperm that are moving and the quality of sperm move-
ment. A normal value for sperm motility is 50% motile
along with an average quality or progression score. The
causes of low sperm motility, the most common semen
analysis finding, are myriad and often reversible.

Recently, however, there has been debate concerning
precisely which semen analysis values are to be consid-
ered “normal,” as controlled studies of fertile and infer-
tile couples suggested other thresholds may be more
appropriate, and sperm production is known to be sus-
ceptible to wide individual, geographic, and seasonal
variation. When assessing semen quality, it is important
to realize that spermatogenesis takes 60 to 80 days to
complete, so that an individual semen analysis reflects
biologic influences occurring 2 to 3 months prior. Like-
wise, medical or surgical therapy directed at improving
semen quality will take several months to become mani-
fest in improved semen quality.

Although seasonal variation exists, sperm production
is a rapid and relatively constant process in humans.
This is in part due to the anatomy of sperm production
within the seminiferous tubules. A cycle of spermato-
genesis involves the division of primitive germ cells
into later germ cells. Many cycles of spermatogenesis
coexist within the germinal epithelium at any one time,
and they are described morphologically as stages.
In addition, there is also a specific organization of
spermatogenic cycles within the tubular space, termed
spermatogenic waves. Although well described in other
mammals, the exact configuration of spermatogenic
waves in humans has been debated. The best evidence
suggests that human spermatogenesis exists in a spiral
or helical cellular arrangement that ensures that
sperm production is a continuous and not a pulsatile
process.

The formal evaluation of sperm shape is termed mor-
phologic assessment. Several descriptive systems exist
to evaluate morphology, and within each system, sperm
are designated normal or abnormal based on specific
size criteria. Although it is essentially judging a book
by its cover, since the late 1980s it has been believed
that sperm morphology may correlate with a man’s
fertility potential as reflected by in vitro fertilization

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 101

Plate 5-3 Reproductive System

AZOOSPERMIA I: Chromosomal
SPERM PRODUCTION abnormalities
PROBLEMS—GENETICS

It is thought that a significant proportion of male infer- Deletion Duplication
tility is due to underlying genetic causes. Currently,
genetic testing for male infertility is based mainly on Inversion Translocation (Balanced, Reciprocal)
abnormalities of sperm concentration. However, it is
clear that the epididymis plays a large role in the devel- Normal spectral
opment of sperm motility and that 200 to 300 genes cytogenetic or
control sperm motility. Thus, as our knowledge of karotype analysis
genomics develops, genetic testing for abnormal motil-
ity will also become routine in the future. 1 23 4 5

Genetic defects are generally divided into three cat- 6 7 8 9 10 11 12
egories. The simplest are point mutations in single genes
that follow the rules of mendelian genetics. The second 13 14 15 16 17 18
category of genetic defects are the chromosomal disor-
ders in which changes in whole segments of chromo- 19 20 21 22 xy
somes occur that are classified as either structural or
numerical in type. As a consequence of structural defects, Pseudoautosomal region 1 Centromere Heterochromatin Pseudoauto-
there is a loss (deletion), gain (duplication), or exchange somal region 2
(balanced defect) of genetic material. Numerical chro-
mosomal defects result in extra or missing chromo- Yp AZFa Yq
somes. The third category is polygenic or multifactorial
genetic defects. These are the most common defects and Y chromosome anatomy P5/proximal-P1 (AZFb)
include most disorders of human biology. A fourth, rare and microdeletions
category of mutations exists, termed mitochondrial dis- }P5/distal-P1
orders, consisting of mutations in nonchromosomal (AZFb/c)
DNA within these subcellular organelles. P4/distal-P1
AZFc (b2/b4)
From 2% to 15% of infertile men with azoospermia
(no sperm count) or severe oligospermia (low sperm sex-determining region (testis-determining region, men with oligospermia and 15% of azoospermic men
counts) harbor a chromosomal abnormality on either SRY ), but it was also home to gene regions that govern have small, underlying deletions in one or more gene
the sex chromosomes or autosomes. A blood test stature, tooth enamel, and hairy ears as well as “junk” regions on the long arm of the Y chromosome (Yq).
for cytogenetic analysis (karyotype) can determine if genes. Now that the genome of the human Y is known, Deletion of the DAZ (deleted in azoospermia) gene in
such a genetic anomaly is present. Patients at risk for it is clear that this chromosome is structurally unique the AZFc region is the most commonly observed
abnormal cytogenetic findings include men with small, as a fertility chromosome. The postulation that dele- microdeletion in infertile men. Fertility is possible in
atrophic testes, elevated follicle-stimulating hormone tions in the long arm of the Y chromosome cause azo- many men with these deletions with in vitro fertiliza-
(FSH, see Plate 1-4) values, and azoospermia. Klinefel- ospermia was made in 1976 and this theoretical region tion and intracytoplasmic sperm injection. A poly-
ter syndrome (47,XXY) is the most frequently detected was termed the Azoospermia Factor (AZF). Currently, merase chain reaction–based blood test can examine the
sex chromosomal abnormality among infertile men (see the positional patterns of deletions (termed microdele- Y chromosome from peripheral leukocytes for these
Plate 1-7). tions) in the AZF region are used to subdivide this gene deletions and is recommended for men with low
region into AZFa, b, c subregions. As many as 7% of or no sperm counts and small, atrophic testes.
Other genetic causes of low sperm concentrations
include XYY syndrome typically associated with tall
stature, decreased intelligence, higher risk of leukemia,
and aggressive, often antisocial behavior. Chromosomal
translocations or inversions are also an infrequent cause
of male infertility and low sperm counts. When seg-
ments of chromosomes are exchanged, a translocation
results. When a chromosome breaks in two places and
the material between the breakpoints reverses orienta-
tion, an inversion results. Such exchanges may either
interrupt important genes at the breakpoint or interfere
with normal chromosome pairing during meiosis
because of imbalances in chromosomal mass. Many
translocations have been associated with male infertility.
In particular, reciprocal and robertsonian translocations
(in which material from chromosomes 13, 14, 15, 21,
and 22 are involved) are eightfold more common in
infertile men than in normal males. In addition, syn-
dromes such as myotonic dystrophy, Noonan syndrome,
46,XX male syndrome and mixed gonadal dysgenesis,
sickle cell anemia, congenital adrenal hyperplasia,
Kallmann syndrome (see Plate 3-17), Prader-Willi syn-
drome, and Kennedy disease are rare but well-described
genetic causes of male infertility.

Before its firm association with male fertility, the Y
chromosome was widely considered a genetic black
hole, an evolved, broken remnant of the X chromo-
some. It was apparent that the Y harbored the male

102 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 5-4 Sperm and Ejaculation

AZOOSPERMIA II: EXCURRENT
DUCT OBSTRUCTION

Excurrent ductal obstruction results in azoospermia Ejaculatory duct
from blockage of the ductal system after sperm exit the Vas deferens
testicle. The posttesticular reproductive tract includes
the epididymis, vas deferens, seminal vesicles, and asso- Epididymis
ciated ejaculatory apparatus (see Plate 3-3). Ductal
obstruction can be due to congenital or acquired causes. Blockage sites for idiopathic obstruction
In cases of idiopathic obstruction, 65% of blockages
will be found in the epididymis, 30% in the vas defer- Enlarged epididymis
ens, and 5% at the level of the ejaculatory duct. Rarely,
intratesticular obstruction of testis efferent ductules Epididymal obstruction No pelvic
(see Plate 3-3) may occur. vas deferens
Enlarged ampullary present
The most common congenital cause of obstruction vas deferens and
is cystic fibrosis (CF) or its variant, congenital absence seminal vesicle Vas deferens
of the vas deferens (CAVD, see Plate 4-22). CF is the stump
most common autosomal recessive genetic disorder in Enlarged ejaculatory duct
the United States and is fatal. Men with CF are missing Cyst Enlarged
parts of the mesonephric ducts that may include the epididymis
epididymis, vas deferens, seminal vesicles, or ejacula- and
tory ducts. CAVD, a “form fruste” of CF, may simply vas deferens
present as infertility and accounts for 1% to 2% of such
cases. On examination, no palpable vas deferens is Unilateral ejaculatory duct obstruction Congenital absence of vas deferens (CAVD)
observed on one or both sides. As many as 80% of
CAVD patients will harbor a detectable CF mutation. restore fertility and reduce symptoms (see Plate 5-9). A to perivasal inflammation causing vasal obstruction.
In addition, 15% will have renal malformations, most substantial proportion of idiopathic cases are associated Bacterial infections such as tuberculosis, Escherichia
commonly unilateral agenesis. The diagnosis is made with CF mutations. coli (in men age >35), or Chlamydia trachomatis may
on physical examination and confirmed by transrectal involve the epididymis or vas deferens, with scarring
ultrasound (TRUS, see Plate 4-12) showing seminal The most common cause of acquired ductal obstruc- and obstruction that may or may not be amenable to
vesicle, ampullary vas deferens, or ejaculatory duct tion is due to vasectomy. Vasectomies are performed microsurgical repair. Commonly, a testis biopsy (see
agenesis or hypotrophy. Most cases are not microsurgi- on 1 to 3 million U.S. men annually for contraception, Plate 5-6) is needed to distinguish between a failure of
cally reconstructable, and sperm retrieval (see Plate 5-7) and approximately 5% of men desire to have the vasec- sperm production and obstruction in azoospermic men.
is required with assisted reproduction to conceive. tomy reversed, most commonly because of remarriage. If normal, obstruction is confirmed, and formal surgical
Groin and hernia surgery can result in inguinal vas investigation of the reproductive tract begins with a
Idiopathic epididymal obstruction is a relatively deferens obstruction, especially in cases in which the vasogram followed by microsurgical reconstruction.
uncommon condition found in otherwise healthy men. Marlex mesh is used in repair. This is thought to be due
It may be linked to prior occult infection, but has also
been shown to be related to CF in that one-third of
affected men harbor CF gene mutations. It is often
amenable to microsurgical reconstruction.

Young syndrome presents with a triad of chronic
sinusitis, bronchiectasis, and obstructive azoospermia.
The pathophysiology of the condition is unclear but
may involve abnormal ciliary function or abnormal
mucus quality, resulting in fluid concretion and block-
age in the fine epididymal ducts. Spermatogenesis is
usually normal, and microsurgical procedures can be
performed to reestablish reproductive tract continuity.

Adult polycystic kidney disease is an autosomal domi-
nant disorder associated with numerous cysts of the
kidney, liver, spleen, pancreas, epididymis, seminal
vesicle, and testis. Disease onset usually occurs in the
twenties or thirties with symptoms of abdominal pain,
hypertension, and renal failure. Infertility is usually sec-
ondary to obstructing cysts in the epididymis or seminal
vesicle, which may be amenable to microsurgery.

Ejaculatory duct obstruction involves blockage of
the ejaculatory ducts—the delicate, paired, collagenous
tubes that connect the vas deferens and seminal vesicles
to the urethra. It is the cause of infertility in 5% of
azoospermic men. It can be congenital, resulting from
müllerian duct (utricular) cysts, wolffian duct (diverticu-
lar) cysts, or congenital atresia or acquired from seminal
vesicle calculi or postsurgical or inflammatory scar
tissue. It presents as hematospermia, painful ejaculation,
or infertility. The diagnosis is confirmed by finding a
low-volume ejaculate, and TRUS reveals dilated seminal
vesicles or dilated ejaculatory ducts. Treatment with
endoscopic unroofing of the ejaculatory ducts can

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 103

Plate 5-5 Reproductive System

AZOOSPERMIA III:
REPRODUCTIVE MICROSURGERY

The role of microsurgery in the treatment of male Microsurgical two-layer
infertility is well established and cost-effective when vasovasostomy
compared to assisted reproduction, including in vitro
fertilization and intracytoplasmic sperm injection. Two-layer Modified
Surgery also attempts to reverse specific pathology and, one-layer
as such, allows for conception at home rather than in
the laboratory. The rise of microsurgery as a surgical Microsurgical Inner layer closure
discipline followed three advances: (1) refinements in vasovasostomy
optical magnification, (2) the development of more approaches
precise microsuture and microneedles, and (3) the
ability to manufacture smaller and more refined surgi- Outer layer closure
cal instruments. In urology, microsurgery was first
applied to renal transplantation and vasectomy reversal. Mucosa to mucosa
Techniques evolved quickly from humble beginnings epididymovasostomy
using borrowed forceps from the local jewelry store (the
“jeweler’s forceps”) and using human hair for fine A2 B1 B2 Vasal fluid sampling
suture material, to its current highly refined state.
B1 A2 “Vest” suture Vasostomy closure
The most commonly performed microsurgical proce- B2 placement after vasogram
dure in urology is vasectomy reversal. The most common
reason for vasectomy reversal is remarriage and the C1 A1
desire for more children. Occasionally, an unfortunate C2
individual will have chronic pain after vasectomy or have
lost a child and desire another. Infection, congenital A1
deformities, trauma, and previous surgery are less fre-
quent indications for vasovasostomy or epididymovasos- C1
tomy (see Plate 5-4). Reproductive tract obstruction is C2
suspected in men with normal FSH and testosterone
levels, normal testis size, and azoospermia. Invagination
epididymovasostomy
Vasal obstruction is generally corrected by vasovasos-
tomy. Although there are several methods for perform- of the epididymal tubule to allow the epididymal tubule hemitransecting the straight segment of the scrotal vas
ing vasovasostomy, including a modified single-layer to be drawn into, or “invaginated” into, the lumen of the deferens, diluted dye or contrast medium is injected into
anastomosis and a strict, two-layer anastomosis, neither vas deferens, theoretically creating an improved water- the vas deferens toward the bladder from the scrotum.
is proven superior to the other. Importantly, optical tight seal. After epididymovasostomy, approximately In plain-film radiographs, contrast delineates the proxi-
magnification with an operating microscope improves 60% to 80% of men will have sperm in the ejaculate. mal vas deferens, seminal vesicle, and ejaculatory ducts
outcomes as smaller sutures can be used, reducing cica- and the site of obstruction can be determined. In addi-
trix formation and failure rates. However, surgeon In cases of idiopathic epididymal obstruction, a tion, the finding of no sperm in the vasal fluid from the
experience is the most critical factor for success. In the similar approach as that taken for vasectomy reversal is testis side of the vas deferens implies that there is an
best hands, 95% to 99% of patients have a return of employed, except for an important difference. Because obstruction present in the epididymis. With this infor-
sperm after vasovasostomy. there is no iatrogenic blockage of the vas deferens mation, the site of obstruction can be accurately deter-
with idiopathic obstruction, the fluid within the mined and the system microsurgically reconstructed
At the time of vasectomy reversal, the vas deferens is vas deferens is sampled from, and the vas deferens with either vasovasostomy or epididymovasostomy.
transected below the vasectomy site. If the fluid egress- inspected by, vasography instead. After puncturing or
ing from the vas deferens contains no sperm, a second
acquired obstruction may exist in the delicate tubules of
the epididymis. As more time passes after vasectomy,
the greater will be the “back-pressure” behind the
blocked vas deferens, causing a “blowout” at some point
in the 18-foot-long microscopic epididymal tubule. A
blowout results in blockage of the tubule as it heals. In
this case, the abdominal vas deferens must be connected
to the epididymis proximal to the blowout to bypass both
sites of obstruction and to reestablish reproductive tract
continuity in a procedure termed epididymovasostomy.

For epididymovasostomy, the epididymis is exposed
by opening the tunica vaginalis that surrounds the testis.
The epididymis is inspected and an individual tubule
selected that appears dilated and is proximal to the
obstruction. Two different approaches to epididymova-
sostomy are now popular: the mucosa-to-mucosa end-
to-side method and the invagination approach. With the
traditional mucosal approach, the opened epididymal
tubule is connected to the cut end of the vas deferens,
with four to six small microsutures placed radially
around the circumference of each. This “inner” layer is
buttressed with another, “outer” layer of radially placed
microsutures to strengthen the delicate connection.
With the invagination method, one, two, or three “vest”
microsutures are placed near but not into the opening

104 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 5-6 Sperm and Ejaculation

AZOOSPERMIA IV: Testicular biopsy
DIAGNOSTIC PROCEDURES

The evaluation of the infertile, azoospermic man Multibiopsy approach FNA mapping approach
involves a direct assessment of spermatogenesis. This
provides definitive evidence of either obstructive or Testis biopsy histology FNA mapping cytology
nonobstructive azoospermia. The testis biopsy is most FNA Technique
commonly used to assess sperm production. The tech-
nique involves a small, open incision in the scrotal wall with a gauze wrap posteriorly. The “testicular wrap” is movements are used to aspirate tissue fragments. After
and testis tunica albuginea under local anesthesia. A a convenient handle to manipulate the testis and also aspiration, the tissue fragments are expelled onto a
small wedge of testis tissue is removed, examined his- fixes the scrotal skin over the testis for the procedure. slide, gently smeared, and fixed in 95% ethyl alcohol.
tologically, and seminiferous tubule architecture and Percutaneous aspiration sites are marked on the scrotal Pressure is applied to each site for hemostasis and a
cellular composition are assessed (for patterns, see Plate skin, 5 mm apart, according to a template. The number routine Papanicolaou stain is performed and the slides
3-21). Alternatively, percutaneous sampling of testis of aspiration sites varies with testis size and ranges from read by a cytologist for the presence or absence of
tissue with a biopsy gun can be used, similar to that 4 (to confirm obstruction) to 15 per testis (for nonob- mature sperm with tails. If sperm are detected, then
employed for prostate biopsy. Although several excel- structive azoospermia). FNA is performed with a sharp- sperm retrieval can proceed at the time of IVF-ICSI
lent descriptions of testis seminiferous epithelium his- beveled, small-gauge needle using the established with a very high possibility of finding sufficient sperm
tology have been reported, no individual classification suction cutting technique. Precise, gentle in-and-out for all oocytes retrieved.
has been uniformly adopted as a standard approach.

A testis biopsy is not usually indicated for cases of
oligospermia (low sperm count), as partial reproductive
tract obstruction is very rare. In addition, although a
single, unilateral testis will define excurrent ductal
obstruction, the finding of two asymmetric testes may
warrant bilateral testis biopsies to best define the
pathology.

With normal sperm production, formal investigation
of the reproductive tract for obstruction is warranted,
beginning with a vasogram (see Plate 5-5). Abnormal
sperm production defines the problem as nonobstruc-
tive azoospermia. The testis biopsy may also indicate
the premalignant condition, intratubular germ cell neo-
plasia, that tends to occur globally within the affected
testis. This condition exists in 5% of men with a con-
tralateral germ cell testis tumor and is more prevalent
in infertile than fertile men.

Since the advent of in vitro fertilization and intracy-
toplasmic sperm injection (IVF-ICSI), a relatively
recent indication for testis biopsy is to determine
whether or not men with nonobstructive azoospermia
have mature sperm present in the testis that may be
used for assisted reproduction. A single testis biopsy
will detect the presence of sperm in 30% of men with
nonobstructive azoospermia. Other surgical and non-
surgical approaches have sought to improve the “yield”
of sperm in cases of testis failure.

It is now clear that men with nonobstructive azo-
ospermia can have “patchy” or “focal” areas of sperm
production in a testis otherwise devoid of mature
sperm. This has led to the development of more sophis-
ticated approaches to testis biopsy, including multibi-
opsy techniques and percutaneous fine-needle aspiration
(FNA) testis “mapping.” As a single testis biopsy is
subject to sampling error, the principle underlying
these advanced approaches is to reduce this error by
more intensive sampling. In return, sperm detection
rates of 60% or more are obtained. With the multibi-
opsy method, four to six individual testis biopsies are
taken from different areas of the testis to increase the
odds of finding sperm in any particular tissue sample.

Similar to other “open” or percutaneous testis biopsy
methods, fine-needle aspiration mapping is performed
under local anesthesia. Unlike these techniques,
however, smaller tissue samples are obtained that are
then examined cytologically instead of histologically. It
is also a diagnostic procedure that creates a geographi-
cal “map” of the testis to justify future and potentially
more invasive attempts at sperm retrieval. FNA
mapping involves wrapping the testis and scrotal skin

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 105

Plate 5-7 Reproductive System

THERAPEUTIC SPERM RETRIEVAL

Sperm retrieval techniques collect sperm from organs Vasal
within the male genital tract. Developed in 1985, ten
years before the description of intracytoplasmic sperm MESA
injection (ICSI), sperm retrieval combined with in vitro PESA
fertilization (IVF) and ICSI allow severely infertile men
the opportunity for fatherhood. Candidate organs for TESE
sperm retrieval include the vas deferens, epididymis, Micro TESE (vertical)
and testicle in obstructed men and the testis in nonob- Micro TESE (horizontal)
structive azoospermic men. Although it is not difficult TESA
to retrieve sperm from men with normal sperm produc-
tion, it can be very difficult to find sperm in men with Sperm retrieval by TESA
testicular failure and nonobstructive azoospermia.
Microdissection TESE
Patients with congenital or acquired obstruction of
the excurrent ductal system at the level of the prostate FNA Map–directed TESE
or the pelvic portions of the vas deferens are candidates
for vasal sperm aspiration. Also included are men with Sperm
ejaculatory failure due to diabetes or spinal cord injury. Incision
Vasal aspiration is performed either coincident with, or
a day in advance of, IVF egg retrieval and is undertaken Micro TESE TESE
in a manner similar to a vasectomy. Through a scrotal TESA
puncture, the vas deferens is identified. Using optical Large-caliber semiferous tubule
magnification, a small incision or puncture is made in
the delicate wall of the vas deferens until the lumen is large incision that exposes the entire testis parenchyma. present in nonobstructive azoospermic men before
entered. Sperm and fluid are aspirated and, after suffi- With an operating microscope, the entire bed of testis IVF-ICSI. Depending on the location, density, and
cient sperm are obtained, the vas deferens wall is closed tissue is examined for sperm-containing seminiferous quantity of sperm found on the map, sperm retrieval
microsurgically; no closure is needed for a puncture tubules that are larger in diameter and more opaque, or may involve TESA, TESE, or microdissection TESE.
vasotomy. Vasal sperm is the most “mature” or fertiliz- whiter, than tubules without active spermatogenesis.
able of all retrieved sperm, having passed through epi- The ability to freeze and thaw retrieved sperm is a
didymal maturation. This is reflected in the fact that Fine-needle aspiration map-directed TESE employs significant advance in the care of azoospermic men. It
pregnancies have been achieved with vasal sperm and a diagnostic mapping procedure (see Plate 5-6) to guide simplifies the timing and orchestration of fertility proce-
intrauterine insemination (IUI) and IVF without ICSI. subsequent sperm retrieval for IVF-ICSI. Information dures, adds convenience to reproductive urologists’
obtained from the map “directs” the TESE, taking schedules, and allows multiple opportunities to conceive
Epididymal sperm aspiration is performed when the advantage of the a priori knowledge that sperm are with IVF-ICSI without repeating surgical sperm retrieval.
vas is either absent, such as with congenital absence of
the vas deferens (CAVD), or is scarred from prior
surgery, trauma, or infection. Two different approaches
to epididymal sperm aspiration are microscopic epididy-
mal sperm aspiration (MESA), in which the epididymis
is explored microsurgically and sperm aspirated from
individual epididymal tubules, and percutaneous epi-
didymal sperm aspiration (PESA), in which sperm are
aspirated blindly from the epididymis after percutaneous
puncture. The most important difference between these
techniques is that individual epididymal tubules are
sampled for sperm with MESA, but multiple epididymal
tubules are sampled with PESA; thus, the overall yield
and bankability of sperm is less with PESA than MESA.
As epididymal sperm are not as “mature” as vasal sperm,
they require IVF-ICSI for pregnancy success.

The newest of the three sperm aspiration techniques,
testicular sperm retrieval, was first reported in 1993,
one year after ICSI. It demonstrated that sperm do not
have to “mature” and pass through the epididymis to
be able to fertilize an egg (with ICSI). Testicular sperm
extraction is indicated for “obstructed” patients and is
also useful for many men with nonobstructive azoosper-
mia. In obstructed men, testis sperm can be retrieved
by needle aspiration (TESA) or percutaneous or open
surgical biopsy (TESE). TESA involves holding the
testis with the epididymis located posteriorly followed
by insertion of a hollow needle (16- to 23-gauge) into
the testis through the stretched skin of the scrotum.

In men with nonobstructive azoospermia, testis biopsy
(TESE) is usually needed to retrieve sufficient sperm for
IVF-ICSI. To improve the likelihood of finding sperm,
a multibiopsy TESE has been described in which many
biopsies are taken until enough sperm are obtained. A
variant of multibiopsy TESE is microdissection TESE,
which involves taking multiple testis biopsies through a

106 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 5-8 Sperm and Ejaculation

Nerves controlling
ejaculation:
Hypogastric plexus

EJACULATORY DISORDERS Neurophysiology of ejaculation

Although commonly viewed as a single event, ejacula- Vas
tion is actually two separate processes, termed emission deferens
and ejaculation. During emission, the semen is “loaded”
into the prostatic urethral chamber. After this, ejacula- Seminal
tion is the forcible expulsion of semen from the penis vesicle
in a series of spurts caused by rhythmic contractions, Prostate
about 1 second apart, of the pelvic muscles. Ejaculation T10-L2
is different from orgasm or climax, the latter being an
event that is centered in the brain that is closely associ- Bladder neck
ated with ejaculation. Perineal
muscles
Disordered ejaculation in which there is no semen S2-S4
produced at the time of climax is called aspermia. This Pudendal nerve
is different from azoospermia (see Plate 5-3), in which
semen is present but contains no sperm. In the absence Retrograde ejaculation
of ejaculate, there can be failure of ejaculation (anejacu-
lation) or ejaculation into the bladder (retrograde ejacu- Electroejaculator for anejaculation
lation). Failure of ejaculation can be a lifelong, primary
event (congenital anorgasmia) or an acquired problem Antegrade
(secondary anorgasmia). The treatment of these condi- Retrograde
tions is different and important to distinguish.
Anejaculation. This condition can be congenital following techniques: prostatic massage for sperm, col-
Similar to a sneeze, ejaculation is a spinal reflex. With or acquired. Congenital anorgasmia occurs in about lection and insemination of nocturnal semen emissions,
both, there is a “point of no return” that occurs after 1/1000 men. Despite the lack of orgasm, nocturnal penile vibratory stimulation or rectal probe electroe-
the reflex is stimulated. Ejaculation is under control of emissions during sleep may occur. Treatment of primary jaculation, or sperm retrieval (see Plate 5-7). Secondary
two nervous systems: the sympathetic (autonomic) anejaculation is difficult, as affected individuals often or acquired anejaculation can be due to the same medi-
nervous system governs emission and the somatic lack sensual awareness. Generally, treatment is sought cations that cause retrograde ejaculation. Anejaculation
nervous system controls ejaculation. Sympathetic when the couple desires a pregnancy, as erections and can also be caused by diabetes, multiple sclerosis, and
nerves arise from thoracolumbar spine at levels T10-L2. sexual performance are otherwise unaffected. Again, sex spinal cord injury. In these cases, penile vibratory
They form the superior hypogastric plexus and run in education has the highest chance of curing this problem. stimulation, rectal probe ejaculation, or surgical sperm
front of the aorta in the back and pelvis. Expulsion of Fertility issues can be bypassed with one or more of the retrieval techniques can be used to achieve fertility.
the ejaculate is governed by the somatic nervous system
through the pudendal nerve (S2-S4). Interruption of
either nervous system input can result in ejaculatory
disorders.

Premature ejaculation. The average time from
vaginal penetration to ejaculation in men is 9 minutes.
Premature ejaculation is present when orgasm occurs
within 1 minute after vaginal penetration, or when
ejaculation occurs too early for female partner satisfac-
tion. This problem occurs in 30% of adult men, and it
is the most common form of male sexual dysfunction.
It can be due to erectile dysfunction, anxiety, and nerve
hypersensitivity and is treatable. Importantly, although
medications can “control” the problem and delay ejacu-
lation, “curing” the problem usually requires sex educa-
tion to learn control and satisfaction. Secondary
premature ejaculation can be improved by normalizing
erection function in many cases.

Retrograde ejaculation. This is a straightforward
diagnosis that requires a history of aspermia, with a
postejaculate urine sample showing sperm. Causes
include medical conditions such as diabetes mellitus,
multiple sclerosis, spinal cord injury, tethered spinal
cord, spina bifida, medications such as alpha-blockers,
tricyclic antidepressants and finasteride, and surgical
procedures such as transurethral prostatic resection
(TURP, see Plate 4-17), V-Y plasty of the bladder neck,
rectal, anterior spinal and retroperitoneal procedures.
The treatment of retrograde ejaculation depends on its
cause. If drug-induced, then the offending medication
should be discontinued. Oral therapy with alpha-ago-
nist agents can help close the bladder neck and avoid
entry of the semen into the bladder during ejaculation.
Sperm can also be “harvested” from the bladder and
used for fertility procedures if needed.

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 107

Plate 5-9 Reproductive System

Ejaculatory duct anatomy

Diagnosis of EDO by
ejaculatory duct manometry

EJACULATORY DUCT Extra-
OBSTRUCTION prostatic
duct
Ejaculatory duct obstruction (EDO) underlies 1% to
5% of male infertility. Although originally described in Intraprostatic
azoospermic men with complete blockage, it is now duct
clear that EDO is a more complex anatomic condition
that can take several forms. Distal Seminal
segment vesicle
The ejaculatory ducts are paired, collagenous, tubes
that commence at the junction of the ampullary vas Prostate
deferens and seminal vesicle, course through the pros-
tate, and empty into the prostatic urethra at the veru- Ultrasound Manometer
montanum. The duct has three regions: an extraprostatic Rectum
portion, a middle intraprostatic segment, and a distal
segment within the verumontanum. Ejaculatory conti- TURED procedure
nence is maintained, and urinary reflux prevented, by
the acute angle of duct insertion into the urethra. Verumontanum
Ejaculatory duct openings
Physiologically, the relationship between the seminal
vesicle and ejaculatory duct is similar to that of bladder Endoscopic view of TURED for EDO
and urethra. Just as bladder outlet obstruction can Before TURED procedure After TURED procedure
result from prostatic blockage, so too can physical
blockage of the ejaculatory ducts cause EDO. By similar Verumontanum Unroofed cyst
reasoning, “functional” or neurologic dysfunction of
the seminal vesicle may be similar to voiding dysfunc- prospective study of these three techniques deemed bladder outlet obstruction, diagnostic ED manometry
tion due to bladder myopathy. At times, a “functional” patency with chromotubation the most accurate way to can differentiate complete from partial, and physical
issue can be mistaken for “physical” ejaculatory duct diagnose ejaculatory duct obstruction. from functional, forms of EDO.
blockage, thus adding further complexity to the diag-
nosis of EDO. Because of the complexity of diagnosing partial Once EDO is confirmed diagnostically, the treat-
EDO, testing has been developed that can differentiate ment is transurethral resection of the ejaculatory ducts
Ejaculatory duct obstruction presents with infertility, physical from functional forms of EDO. Similar to the (TURED), performed in an outpatient setting under
postejaculatory pain, or hematospermia. Low-volume concept of urodynamics for bladder outlet obstruction, anesthesia. Similar to transurethral prostatic resection
azoospermia defines complete or classic EDO and rep- ejaculatory duct manometry measures the “opening for benign prostatic hypertrophy (see Plate 4-17), the
resents the physical blockage of both ducts. Unilateral pressures” of the ejaculatory duct, defined as the pres- technique combines cystourethroscopy with resection
complete or bilateral partial physical obstruction results sure above which fluid from the seminal vesicle that of the verumontanum in the midline (for complete
in incomplete or partial EDO. Both are associated with passes through the ejaculatory duct enters the prostatic obstruction) or laterally (for unilateral obstruction)
either one or more of low ejaculate volume, postejacula- urethra. Fertile patients have remarkably consistent and with cutting current. When performed correctly,
tory pain, or hematospermia. However, partial EDO is low opening pressures, defined as <45 cm H2O, and cloudy, milky fluid is usually seen refluxing from the
uniquely associated with oligoasthenospermia. infertile men with EDO have significantly higher ED opened ducts. Postoperatively, a small Foley catheter is
pressures. Based on the well-established pressure-flow placed for 24 hours. Impressive and durable increases
Ejaculatory duct obstruction can result from seminal concept used to evaluate ureteropelvic junction and in semen quality are common after the procedure.
vesicle calculi, müllerian duct (utricular) or wolffian
duct (diverticular) cysts, postinflammatory scar tissue,
medications or medical conditions, calcification, or
congenital ductal atresia. With congenital blockage,
genetic evaluation for cystic fibrosis gene mutations is
indicated. Transrectal ultrasound may reveal dilated
seminal vesicles, ejaculatory duct cysts, calculi, absence
of the vas, or müllerian duct remnants. Associated risk
factors for EDO include prior urinary tract infection,
epididymitis, perineal trauma, orchalgia, and perineal
pain. It is important to discontinue medications that
may impair ejaculation. Although rare, a digital rectal
examination revealing enlarged, palpable seminal vesi-
cles may suggest EDO.

Procedures used to confirm the diagnosis of EDO
include seminal vesicle sperm aspiration (a normal
seminal vesicle should not have sperm in it, unlike a
blocked one), contrast seminovesiculography (injection
of contrast in a manner similar to vasography to locate
the obstruction), and seminal vesicle chromotubation
(a variant of vesiculography in which dye is injected
and ejaculatory duct patency assessed visually). A

108 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

SECTION 6

THE VULVA

Plate 6-1 Reproductive System
Anterior commissure of labia majora
Mons pubis
Prepuce of clitoris

Pudendal cleft (groove
or space between the
labia majora)

EXTERNAL GENITALIA Vaginal orifice Perineal raphe Anus Glans of clitoris
(over perineal body) Frenulum of clitoris
The vulva includes those portions of the female genital External urethral orifice
tract that are externally visible in the perineal region. Labium majus
The mons veneris, overlying the symphysis pubis, is a Labium minus
fatty prominence, covered by terminal sexual (pubic) Openings of paraurethral
hair that functions as a dry lubricant during intercourse. (Skene) ducts
From the mons, two longitudinal folds of skin, the labia Vestibule of vagina
majora, extend in elliptical fashion to enclose the vulval (cleft or space surrounded
cleft. They contain an abundance of adipose tissue, by labia minora)
sebaceous glands, and sweat glands and are covered by Opening of greater
hair on their upper outer surfaces. The anterior com- vestibular (Bartholin) gland
missure marks their point of union at the mons. Poste-
riorly, a slightly raised connecting ridge, the posterior Hymenal caruncle
commissure or fourchette, joins them. Between the
fourchette and the vaginal orifice, a shallow, boat- Vestibular fossa
shaped depression, the fossa navicularis, is evident. The
labia minora are thin, firm, pigmented, redundant folds Frenulum of labia minora
of skin, which anteriorly split to enclose the clitoris;
laterally, they bound the vestibule and diminish gradu- Posterior commissure of labia majora
ally as they extend posteriorly. The skin of the labia
minora is devoid of hair follicles, poor in sweat glands, Annular hymen Septate hymen Cribriform hymen Parous introitus
and rich in sebaceous glands. The skin of the labium
majus, and to a less extent the labium minus, is subject of the lateral boundary of the vaginal orifice. Each duct, both sides by stratified squamous epithelium. As a rule,
to most of the same dermatologic pathologies as other approximately 1.5 cm in length, passes inward and lat- it shows great variations in thickness and in the size and
areas of skin. erally to the deeply situated vulvovaginal glands. The shape of the hymenal openings (e.g., annular, septate,
Bartholin glands are situated posterior to the 3- and cribriform, crescentic, fimbriate). After tampon usage,
The clitoris, a small, cylindrical, erectile organ situ- 9-o’clock locations, which is important clinically when coitus, and childbirth, the shrunken remnants of the
ated at the lower border of the symphysis is composed a Bartholin gland abscess is considered in patients with hymen are known as carunculae hymenales or hymenal
of two crura, a body, and a glans. The crura lie deeply, labial swelling. caruncles. The presence or absence of an intact hymen
in close apposition to the periosteum of the ischiopubic is insufficient to determine the presence or absence of
rami. They join to form the body of the clitoris, which The hymen is a thin, vascularized membrane that past sexual activity.
extends downward beneath a loose prepuce to be separates the vagina from the vestibule. It is covered on
capped by the acorn-shaped glans. Only the glans of the
clitoris is generally visible externally between the two
folds formed by the bifurcation of the labia minora.
When the clitoris is abnormally enlarged as a result of
exposure to excess androgens, the clitoral index (the
product of the sagittal and transverse diameters of the
glans, in millimeters; normal <35 mm2) is used to grade
the degree of enlargement.

The vestibule becomes apparent on separation of the
labia. Within it are found the hymen, the vaginal
orifice, the urethral meatus, and the opening of Skene
and Bartholin ducts. The external urethral meatus is
situated upon a slight papilla-like elevation, 2 cm below
the clitoris. In the posterolateral aspect of the urinary
orifice, the openings of Skene ducts lie. They run below
and parallel to the urethra for a distance of 1 to 1.5 cm.
Bartholin ducts are visible on each side of the vestibule,
in the groove between the hymen and the labia minora,
at about the junction of the middle and posterior thirds

110 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-2 The Vulva

Superficial fatty (Camper) layer Subcutaneous
tissue
Deeper membranous
(Scarpa) layer

Rectus sheath (anterior layer)

Aponeurosis of external oblique muscle

Superficial inguinal ring

Anterior superior iliac spine

Round ligament of uterus
and coverings (cut)

Inguinal ligament (Poupart)

Pubic tubercle

PUDENDAL, PUBIC, AND Saphenous opening
INGUINAL REGIONS
Pubic symphysis
The superficial fascia of the anterior abdominal wall has
been cut away, exposing the aponeurosis of the external Fascia lata of thigh
oblique muscle, with the linea alba in the midline and
the linea semilunaris laterally outlining the rectus com- Suspensory ligament of clitoris
partment beneath. Below are the inguinal ligaments,
continuous with the fascia lata of the thighs, and the Ischiopubic ramus
structures of the perineum superficial to the inferior
fascia of the urogenital diaphragm. The fascial layers of Superficial perineal (Colles) fascia (cut
the canal of Nuck emerge from the superficial inguinal away) to open superficial perineal space
ring and descend toward the lateral margin of the
labium majus. These layers are composed of fibers both Ischiocavernosus muscle
from the aponeurosis of the external oblique and from
the transversalis fascia. The innermost layer is closely Perineal membrane
applied to the round ligament, which becomes more
attenuated as it descends and eventually terminates by Deep perineal (investing or Gallaudet)
fine, fingerlike attachments in the labium majus. Within fascia (partially cut away)
this sac is a vestigial remnant of peritoneum, the homo-
logue of the tunica vaginalis in the male. The canal of Ischial tuberosity
Nuck may persist in the child or the adult in a patent
form and may then give rise to inguinal hernias or the Fat body of ischioanal fossa
so-called hydrocele feminae. Adjacent to the terminal
portion of this process on the right side is Colles fascia, Superficial perineal (Colles) fascia (cut edge turned down)
attached laterally to the ischiopubic ramus and inferi-
orly to the fasciae, covering the superficial transverse Superficial transverse perineal muscle
perineal muscle, which forms the upper margin of the
ischiorectal fossa. Bulbocavernosus muscle (covers bulb of vestibule)

Lateral to the subcutaneous inguinal ring and below Round ligament of uterus and coverings
the inguinal ligament lies the fossa ovalis surrounding
the femoral artery and vein. Close to the fossa are the Superficial perineal (Colles) fascia
origins of the inferior epigastric, iliac circumflex, and
superficial external pudendal vessels. Peritoneum

To expose the superficial muscles and inferior fascia Urachus Vesical fascia
of the urogenital diaphragm or triangular ligament,
Colles fascia has been cut away on the left side. Closely Transversalis fascia Uterovaginal fascia
applied to the left lateral wall of the vagina and lying Rectal fascia
below the labium majus is the bulbocavernosus muscle, Subcutaneous tissue Fatty Rectus
which passes from the central tendinous point of the Membranous abdominis
perineum to be attached in the corpus cavernosum and muscle Uterus
suspensory ligament of the clitoris. This muscle also is
a constrictor of the introitus. At right angles to the Rectus sheath (anterior layer)
bulbocavernosus muscle and similarly attached to the Pubic symphysis
central tendinous point is the superficial transverse
perineal muscle, which runs laterally to the tuberosity Inferior (arcuate) pubic ligament Bladder
of the ischium and helps support the midportion of the Vagina
pelvic floor. The ischiocavernosus muscle is the hypot- Transverse perineal ligament Rectum Levator ani muscle
enuse of the triangle formed by the bulbocavernosus
and the superficial transverse perineal muscles and runs Suspensory ligament of clitoris
from the tuberosity of the ischium upward to be inserted
in the crus of the clitoris, which it covers for most of Sphincter urethrae and sphincter
its length. Within the triangle is the inferior fascia of urethrovaginalis muscles
the urogenital diaphragm, which blends with the deep
fibers of Colles fascia. The triangular shape of the Perineal membrane Anococcygeal body
whole urogenital diaphragm stands out clearly in this
view, with the apex at the symphysis pubis, the ischio- Superficial perineal space
pubic rami forming the sides, and the transverse
Superficial perineal (Colles) fascia Inferior fascia
Perineal body of pelvic diaphragm

Superior fascia of pelvic diaphragm

External anal sphincter muscle

perineal muscles connected by the central tendinous joining to form a single ligament anterior to the urethra
point of the perineum, the base. The external anal and posterior to the vagina. Elements from these cover
sphincter sends interdigitating fibers to join those of the the outer surfaces of the pelvic viscera, where they are
transverse perineal, bulbocavernosus, and pubococ- known as the endopelvic fascia. Composed of smooth
cygeus muscles in the central perineum. muscle as well as fibrous tissue, they are thin superiorly
where they lie just beneath the reflections of the pelvic
The lateral view illustrates the manner in which the peritoneum, but they become thicker as they approach
muscles and fasciae of the urogenital diaphragm are their attachments to the upper fasciae of the urogenital
applied to and support the pelvic viscera. The urogeni- diaphragm and levator ani muscles.
tal fascia is composed of a superior and an inferior layer

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 111

Plate 6-3 Reproductive System

Bulbocavernosus muscle with Suspensory ligament of clitoris

deep perineal (investing or Gallaudet) Ischiocavernosus muscle

fascia partially removed Clitoris Bulb of vestibule

Superficial perineal space Perineal membrane
(pouch or compartment)
Greater vestibular
Ischiopubic ramus (Bartholin) gland
with cut edge of
superficial perineal Bulbocavernosus
(Colles) fascia muscle
(cut away)
PERINEUM Perineal
membrane Superficial
The mons veneris in front, the buttocks behind, and the transverse
thighs laterally bound the perineum. More deeply, it is Ischial perineal
limited by the margins of the pelvic outlet, namely, the tuberosity muscle
pubic symphysis and arcuate ligament, ischiopubic
rami, ischial tuberosities, sacrotuberous ligaments, Sacro- Perineal
sacrum, and coccyx. A transverse line joining the ischial tuberous body
tuberosities divides the perineum into an anterior uro- ligament
genital and a posterior anal triangle.
Gluteus
The perineal floor is composed of skin and two layers maximus
of superficial fasciae—a superficial fatty stratum and a muscle
deeper membranous one. The former is continuous
anteriorly with the superficial fatty layer of the abdomen Ischioanal fossa Coccyx Obturator fascia
(Camper fascia) and posteriorly with the ischiorectal Anococcygeal (ligament) body
fat. The deeper, membranous layer of the superficial Tendinous arch of
perineal fascia (Colles fascia) is limited to the anterior levator ani muscle
half of the perineum. Laterally, it is attached to the
ischiopubic rami; posteriorly, it blends with the base of External anal sphincter muscles Inferior fascia of pelvic diaphragm (cut)
the urogenital diaphragm; and anteriorly, it is continu-
ous with the deep layer of the superficial abdominal Levator ani muscle
fascia (Scarpa fascia).
Urethra
The urogenital diaphragm is a strong, musculomem-
branous partition stretched across the anterior half Crus of clitoris Sphincter urethrae muscle
of the pelvic outlet between the ischiopubic rami. It Ischiopubic ramus Perineal membrane (cut and reflected)
is composed of superior and inferior fascial layers Compressor urethrae muscle
between which are located the deep perineal muscles,
the sphincter of the membranous urethra, and the Bulb of vestibule
pudendal vessels and nerves. It is pierced by the urethra
and vagina. Sphincter urethrovaginalis muscle

The anal triangle is delineated by the superficial peri- Perineal membrane
neal muscles anteriorly, the sacrotuberous ligaments
and margins of the gluteus maximus laterally, and the Greater vestibular (Bartholin) gland Vagina
coccyx posteriorly. It contains the anal canal and its Deep transverse perineal muscle
sphincters, the anococcygeal body, and the ischiorectal
fossae. point of the perineum and to the inferior fascia of the orifices. It is a common fibrous point of attachment for
urogenital diaphragm and insert anteriorly into the the bulbocavernosus, the superficial and deep trans-
The ischiorectal fossae are prismatic in shape. The corpora cavernosa clitoris. They are sometimes termed verse perineal, the levator ani, and the external anal
lateral wall of each is formed by the obturator internus the sphincter vaginae. Spasms in this muscle group are sphincter muscles. This area is often referred to as the
fascia, and its medial wall by the fascia overlying the often found in patients with vaginismus. The pair of perineal body.
levator ani, the coccygeus, and the external anal sphinc- deep transverse perineal muscles (within the urogenital
ter muscles. The tendinous arch marks its apex. Ante- diaphragm) is interrupted near the midline by the The anococcygeal body is of fibromuscular consis-
riorly, the fossa extends between the urogenital and vagina, into which they insert. tency and extends from the anus to the coccyx. It
pelvic diaphragms. Posteriorly, the sacrotuberous liga- receives fibers from the external anal sphincter and the
ment and gluteus maximus muscle limits it. The con- The central point of the perineum lies at the base of levator ani muscles and serves as a support for the anal
tents of the ischiorectal fossa include an abundance of the urogenital diaphragm between the vaginal and anal canal.
fat, the inferior hemorrhoidal vessels and nerves, and
the internal pudendal vessels and nerves within Alcock
canal.

The muscles of the perineum include the bulbocav-
ernosus, the ischiocavernosus, the superficial and deep
transverse perineal muscles, the sphincter of the mem-
branous urethra, and the external anal sphincter. These
muscles, in general, correspond to their homologues in
the male. The ischiocavernosus muscles are smaller
than in the male. They overlie and insert into the crura
of the clitoris instead of into the crura of the penis, as
in the male. The bulbocavernosus muscles surround the
orifice of the vagina and cover the vestibular bulbs.
They are attached posteriorly to the central tendinous

112 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-4 The Vulva

Superficial circumflex iliac vein node Inguinal ligament

Cloquet or
Rosenmüller node

Femoral vessels

Deep femoral
node

LYMPHATIC DRAINAGE—
EXTERNAL GENITALIA

A network of lymphatic anastomoses drains the external Superficial epigastric vein node Fascia lata
genitalia, the lower third of the vagina, and the peri-
neum. Bilateral or crossed extension and drainage is Superficial external pudendal vein node
common. The superficial femoral nodes are reached Saphenous vein node
through the superficial external pudendal lymphatic
vessels, although the superficial external epigastrics may External oblique fascia External iliac nodes
also play a role. From the region of the clitoris, deeper Inferior epigastric vessels External iliac vessels
lymphatic vessels may pass direct to the deep femoral Conjoined tendon
nodes, particularly to Cloquet node in the femoral Round ligament
canal, or through the inguinal canal to the external iliac
nodes. Cloquet node is thought to be the sentinel node Exposure of external iliac nodes through inguinal canal
between the superficial and deep inguinal/obturator
lymph nodes. Sometimes, intercalated nodes may be nodes and represent the greatest concentration of drained by the superficial femoral lymphatics and send
encountered in the prepubic area or at the external lymph nodes in the female. efferent vessels to nodes higher in the chain and to the
inguinal ring. The lowermost portion of the vagina, like external iliac nodes.
the vulva, may drain to the femoral nodes. This complex A few constant nodes are usually associated with the
network of lymph nodes is clinically important, for deeper lymphatic trunks along the femoral vessels. Knowledge of the lymphatic drainage of the perineum
these are the nodes to which cutaneous and vulvovagi- These may be situated on the mesial aspect of the can be helpful in the assessment and treatment of
nal gland malignancies may drain. Regional lymph femoral vein, above and below its junction with the patients with vulvar cancers, where lymphatic mapping
node dissections are routinely performed in the surgical saphenous vein. The highest of the deep femoral nodes and sentinel lymph node biopsy may be applied. The
treatment of vulvar cancer as the status of regional lies within the opening of the femoral canal (Cloquet sentinel node(s) are those nodes that directly drain the
lymph nodes is essential for therapeutic planning and or Rosenmüller node). The deep femoral nodes receive primary tumor and are thought to predict the meta-
overall prognosis. Superficial nodes in the groin may afferent lymphatics directly or indirectly from the parts static status of the upper nodes in the groin.
also become enlarged when significant inflammation is
present in vulvar structures (e.g., Bartholin gland
infections).

The inguinal lymph nodes, both superficial and deep,
lie within the subcutaneous tissue roughly overlying the
femoral triangle (“femoral” lymph nodes). Lymphatic
vessels tend to follow the course of veins draining a
particular region. The lymph nodes are arranged in
groups or chains in close relation to the vessels. The
nodes found in this region are generally further referred
to as the superficial and deep inguinal lymph nodes.

The superficial femoral nodes are a group of nodes
found in the loose, fatty connective tissue of the femoral
triangle between the superficial and deep fascial layers.
These nodes receive lymphatic drainage from the exter-
nal genitalia of the vulvar region, the gluteal region, and
the entire leg, including the foot: The saphenous nodes
drain the lower extremities, whereas the superficial cir-
cumflex nodes drain the posterolateral aspect of the
thighs and buttocks.

Afferent vessels from the lower abdominal wall and
the upper superficial aspects of the genitalia extend to
the superficial epigastric nodes in the abdominal wall
above the symphysis. The superficial external pudendal
nodes drain the external genitalia, the lower third of the
vagina, the perineum, and the perianal region. Efferent
lymphatic vessels from all the superficial femoral nodes
drain to the more proximal superficial inguinal (femoral)
nodes, the deep inguinal (femoral) nodes, and the exter-
nal iliac nodes. Efferent lymphatics from this group of
nodes penetrate the fascia lata to enter the deep femoral

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 113

Plate 6-5 Reproductive System

Superficial perineal space
Ischiocavernosus muscle
Posterior labial artery
Bulbocavernosus muscle
Dorsal artery of clitoris
Deep artery of clitoris

Bulb of vestibule

Compressor urethrae
muscle

BLOOD SUPPLY OF PERINEUM Perineal membrane
Artery to bulb of vestibule

The perineum and vulva are richly supplied with blood Greater vestibular
vessels, which become clinically significant during (Bartholin) gland
childbirth and surgical procedures. Blunt trauma to the
area, such as straddle injuries in children, can result in Internal pudendal
significant bleeding or hematoma formation when (clitoral) artery
vessels are ruptured and bleeding into the loose com-
partments of the perineum occurs. Perineal membrane
(cut away)
The internal pudendal artery in the female is a far
smaller vessel than it is in the male, though its course Perineal artery (cut)
is generally the same in both sexes. When leaving the
lesser pelvis through the lower part of the greater sciatic Perineal Internal pudendal artery
foramen, it enters the ischiorectal fossa through the artery in pudendal canal (Alcock)
lesser sciatic foramen. Here, accompanied by its venae
comites and the pudendal nerve, it lies in a fibrous canal Inferior rectal artery
(Alcock canal) formed by the fascia covering the obtura-
tor internus muscle. The branches of the internal Superficial perineal (Colles) fascia (cut
pudendal artery include small ones to the gluteal region, and reflected) to open superficial perineal space
the inferior hemorrhoidal artery, the perineal artery,
and the artery of the clitoris. The pudendal artery (and Superficial transverse Deep transverse perineal muscle
vein) is closely associated with the pudendal nerve as it perineal muscle External anal sphincter muscle
passes the ischial spine near the insertion of the sacro-
spinous ligament (on the dorsal aspect of the coccygeal Note: Deep perineal (investing or Gallaudet) fascia removed from muscles of superficial perineal space.
muscle), placing it at risk when sacrospinous colpopexy
is performed. (A rare complication of this operation is the Bartholin gland. The urethral artery runs medial- The blood supply of the vulva and perineum is richly
massive hemorrhage from the inferior gluteal or puden- ward toward the urethra and anastomoses with branches connected to the vascular supply of the entire vaginal
dal arteries.) from the artery of the bulb. The deep artery of the barrel, the cervix, and the uterus through a number of
clitoris pierces the fascial floor of the deep compart- ascending and descending anastomoses. This vascular
The inferior hemorrhoidal artery pierces the wall of ment just medial to the corpus cavernosum of the cli- net surrounds the vaginal canal, with major trunks
Alcock canal and passes medially through the ischiorec- toris, which it enters. The dorsal artery of the clitoris running in the lateral vaginal wall at the 3- and 9-o’clock
tal fat to supply the anal canal, anus, and perineal area. leaves the deep perineal compartment just behind the locations. Trauma to these areas, as with a vaginal deliv-
The perineal artery pierces the base of the urogenital transverse pelvic muscle and runs over the dorsum of ery, can result in significant blood loss that may be
diaphragm to enter the superficial perineal compart- the clitoris to the glans. difficult to control.
ment, where it supplies the ischiocavernosus, bulbocav-
ernosus, and transverse perineal muscles. A constant
transverse perineal branch runs along the superficial
transverse perineal muscle to the central point of the
perineum. The terminal branches of the perineal artery,
the posterior labial arteries, pierce the deep layer of the
superficial perineal fascia (Colles fascia) to the labia.

The artery of the clitoris enters the deep compart-
ment of the urogenital diaphragm and runs along the
inferior ramus of the pubis in the substance of the deep
transverse perineal muscle and the sphincter of the
membranous urethra, ending in four branches, which
supply chiefly the erectile tissue of the superficial
perineal compartment. The artery of the bulb passes
through the inferior fascia of the urogenital diaphragm
to supply the cavernous tissue of the vestibular bulb and

114 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-6 The Vulva

Anterior labial nerve
(from ilioinguinal nerve)

Dorsal nerve of clitoris

Posterior labial nerves

Superficial Branches
of perineal
Deep
nerve

Perineal branch of
posterior femoral
cutaneous nerve

INNERVATION OF EXTERNAL Dorsal nerve of
GENITALIA AND PERINEUM clitoris passing
superior to perineal
The musculature and integument of the perineum are membrane
innervated mainly by the pudendal nerve. Derived from
the anterior rami of the second, third, and fourth sacral Perineal nerve
nerves, it leaves the pelvis through the greater sciatic
foramen, between the piriformis and coccygeus muscles, Pudendal nerve in
and crosses beneath the ischial spine on the mesial side pudendal canal
of the internal pudendal artery. It then continues within (Alcock) (dissected)
Alcock canal in the obturator fascia on the lateral wall
of the ischiorectal fossa, toward the ischial tuberosity. Inferior cluneal
The pudendal nerve divides into three branches: (1) nerves
The inferior hemorrhoidal nerve pierces the medial
wall of Alcock canal, traverses the ischiorectal fossa, and Gluteus maximus
supplies the external anal sphincter and perianal skin. muscle (cut away)
(2) The perineal nerve runs for a short distance in
Alcock canal and divides into a deep and a superficial Sacrotuberous ligament
branch. The deep branch sends filaments to the exter-
nal anal sphincter and levator ani muscles and then Perforating cutaneous nerve
pierces the base of the urogenital diaphragm to supply
the superficial and deep perineal muscles, the ischio- Inferior anal (rectal) nerves
cavernosus and bulbocavernosus muscles, and the
membranous urethral sphincter. The superficial branch Anococcygeal nerves
divides into medial and lateral posterior labial nerves,
which innervate the labium majus. (3) The dorsal nerve Ischial spine
of the clitoris passes through the urogenital diaphragm
to the glans of the clitoris. Ischial tuberosity

A number of nerves innervate the perineal skin. The Produces anesthesia of pudendal and other nerves of perineal area
anterior labial branches of the ilioinguinal nerve (L1)
emerge from the external inguinal ring to be distributed regional nerve blockade. A pudendal nerve block can 0.5% to 1.0% local anesthetic solution is deposited.
to the mons veneris and the upper portion of the labium be accomplished through either a transcutaneous or This blocks the internal pudendal nerve, as it
majus. (Extreme flexion of the leg during childbirth or transvaginal approach, though the former has generally passes dorsal to the spine just before entering Alcock
vaginal operative procedures can result in temporary or fallen out of favor. In the transcutaneous approach, canal.
permanent loss of function of this nerve.) The external intradermal wheals are made bilaterally, midway
spermatic branch of the genitofemoral nerve (L1, 2) between the rectum and the ischial tuberosities. With In the transvaginal approach to a pudendal nerve
accompanies the round ligament through the inguinal the middle and index fingers of the left hand in the block, the needle is placed within a needle guide and
canal and sends twigs to the labium. The perineal vagina, a 10-cm needle is guided to a point just under directed to the ischial spine by traversing the lateral
branches of the posterior femoral cutaneous nerve (S1, and beyond the ischial spine, where 10 to 15 mL of a vaginal wall. This approach is often faster and better
2, 3) run forward and medial in front of the ischial tolerated than a transcutaneous route.
tuberosity to the lateral margin of the perineum and
labium majus. Branches of the perineal nerve (S2, 3, 4)
include the dorsal nerve of the clitoris and the medial
and lateral posterior labial branches to the labium
majus. The inferior hemorrhoidal branch of the puden-
dal nerve (S2, 3, 4) contributes to the supply of the
perianal skin and accounts for the sensory portion of
the “anal wink” reflex. The perforating cutaneous
branches of the second and third sacral nerves perforate
the sacrotuberous ligament and turn around the infe-
rior border of the gluteus maximus to supply the
buttocks and contiguous perineum. The anococcygeal
nerves (S4, 5, and coccygeal nerve) unite along the
coccyx and then pierce the sacrotuberous ligaments to
supply the anococcygeal area.

The course and distribution of the pudendal nerve
make it an ideal candidate for safe and effective

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Plate 6-7 Reproductive System

DERMATOSES

The skin of the vulva is subject to the same dermatoses Folliculitis and Herpes genitalis
that occur over the rest of the body surface. Those furunculosis
described here are only a few of the more common Intertrigo
lesions. Tinea cruris
presentation is persistent vulvar itching. The presence Psoriasis
Folliculitis refers to a papular or pustular inflamma- of similar lesions on the scalp and extensor surfaces of characteristic appearance and distribution. Unfortu-
tion about the apertures of hair follicles, caused by the extremities is helpful in establishing the diagnosis. nately, there is no cure for psoriasis, but it can be
Staphylococcus aureus or mixed organisms. Furuncles are The general characteristics of psoriasis include (1) red- controlled with treatment. Treatment begins with
larger and more deeply situated and exhibit the typical dened, slightly elevated, dry and sharply demarcated avoidance of irritants, the use of emollients and mois-
signs of inflammation about a central core of purulent patches covered with silvery-white scales; (2) a charac- turizers, and limited use of topical steroids. Topical
exudate. Contributory factors for a staphylococcal pyo- teristic distribution; (3) the presence of nail changes; antibiotics or antifungal therapy is prudent when sig-
derma infection include the irritation of tight under- (4) history of chronicity or recurrence; and (5) a familial nificant skin cracking has occurred. Many of the treat-
clothes or vulvar pads, lack of cleanliness, diabetes, and tendency. The diagnosis is usually established by its ments used to treat psoriasis elsewhere are too harsh to
lowered immune competence (natural or iatrogenic). use on genital skin.
Topical therapy with sitz baths, topical antibiotics, and
interim drying and ventilation are usually sufficient.
Systemic antibiotic therapy may be appropriate in
selected cases.

Herpes genitalis is a herpes simplex infection of the
vulva similar to that which occurs about the lips, nose,
cornea, or, in the male, on the penis. It is a superficial,
localized, and frequently recurring lesion, caused by the
herpes virus. Herpetic vulvitis appears as groups of
vesicles on an edematous, erythematous base. The blis-
ters tend to break, with the formation of small ulcers,
or they dry and become covered with crusts. Initial
infections are often extremely painful, even to the
extent of causing urinary retention. Symptoms of recur-
rent infections are usually limited to local pruritus or
burning. Herpes zoster is differentiated by the distribu-
tion of vesicles along a nerve trunk and the occurrence
of a prodromal period of fever, malaise, and localized
pain.

Intertrigo is a superficial inflammation of the external
genitalia. It appears as a red or brownish discoloration,
particularly of the interlabial sulci, the furrows between
the vulva and thighs, and the inner aspect of the thighs.
It is caused by chafing, especially in obese women,
during hot weather. Anything that contributes to local
moisture, such as a persistent vaginal discharge or
urinary incontinence, will prolong the irritation. A der-
matophytosis frequently is superimposed.

Tinea cruris is a fungus infection or ringworm of the
groin, usually caused by Epidermophyton floccosum. The
lesions consist of discrete patches, which may cover
the vulva, pubis, lower abdomen, groin, and inner
thighs. They are pink or red in color, scaly, and sharply
demarcated from normal skin. Secondary inflammatory
changes may be superimposed as the result of scratch-
ing, moisture, and irritation. The condition may be
spread by direct contact or through use of contaminated
clothing. The diagnosis may be corroborated by culture
on Sabouraud medium or by examination of superficial
scales placed in a hanging drop of 10% sodium or
potassium hydroxide in order to establish the presence
of the characteristic branching mycelia.

Psoriasis of the vulva is not uncommon, affecting up
to 2% of the general population. The most common

116 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-8 The Vulva

ATROPHIC CONDITIONS

Senile atrophy may follow natural or surgical meno- Senile atrophy Kraurosis vulvae
pause, or loss of ovarian function by chemotherapy
(alkylating agents) or x-ray therapy. It is the result of Leukoplakia Lichenification
the loss of estrogen stimulation to the genital tract. The plaques or as a generalized lesion involving the clitoris, vulva is preceded by these changes in almost 50% of
skin changes are variable in degree and slowly progres- prepuce, labia minora, posterior commissure, perineum, cases.
sive. With the loss of subcutaneous fat beneath the mons and perianal areas. The lesion is grayish white in color,
veneris and labia majora, the vulva assumes an increas- thickened, and almost asbestos-like in appearance. Prolonged scratching may provoke lichenification, a
ingly shrunken appearance. The pubic hair becomes Fissures and ulcerations are common. The histologic secondary change in the skin. The skin has a thickened,
thin, sparse, and brittle. The labia minora, clitoris, picture includes hyperkeratosis, increase in the stratum leathery appearance in which the normal markings
and prepuce are reduced in size. The skin becomes granulosum, acanthosis, lymphatic infiltration of the appear accentuated. When moisture is present, the
thin, inelastic, shiny, and occasionally depigmented. cutis, and destruction of the elastic fibers of the corium. lesion assumes a grayish-white, soggy appearance.
Microscopically, the stratified squamous epithelium is Differentiation of this from other lesions of the vulva Hyperkeratosis, parakeratosis, acanthosis, and prolon-
reduced in thickness and there is a loss of elastic fibers. is important because squamous cell carcinoma of the gation of the retial pegs can be seen histologically, but
The underlying connective tissue shows evidence of the subepithelial elastic fibers are not destroyed.
decreased vascularity and increased fibrosis.

In the past, the terms kraurosis vulvae and leukoplakia
were applied to these atrophic changes. The term leu-
koplakia was applied when there was primarily an
inflammatory process; kraurosis vulvae was essentially
an extreme degree of atrophy. These terms have been
discarded in part because abnormal lesions of the vulva
require biopsy to establish a correct diagnosis and to
rule out the possibility of an occult malignancy (present
in 4% to 6% of cases of lichen sclerosis).

Atrophic vulvitis (the former kraurosis vulvae) is a
progressive sclerosing atrophy of marked degree,
resulting in stenosis of the vaginal opening and efface-
ment of the labia minora and clitoris. Dyspareunia is a
common complaint because of dryness and the shrink-
age of the vaginal introitus and canal. The vulvar skin
is thin, dry, shiny, depigmented, and yellow-white. The
tension of parts often causes cracks, excoriations, and
annoying pruritus.

These atrophic changes must be differentiated from
the changes of lichen sclerosus. Microscopically, the
epithelium becomes markedly thinned with a loss or
blunting of the rete ridges. In some cases, there is also
a thickening or hyperkeratosis of the surface layers.
Inflammation is usually present. When lichen sclerosus
is present, there is usually a diffuse whitish change to
the vulvar skin. The vulvar skin often appears thin, and
there may be scarring and contracture beyond what is
seen with simple estrogen deprivation. In addition, fis-
suring of the skin is often present, accompanied by
excoriation secondary to itching. It is nonneoplastic and
involves glabrous skin as well as the vulva. Areas of
squamous hyperplasias (formerly called hyperplastic
dystrophy without atypia) also appear as whitish lesions
in general, but the tissues of the vulva usually appear
thickened and the process tends to be more focal or
multifocal than diffuse. (The term lichen sclerosus et atro-
phicus was dropped because the epithelium is metaboli-
cally active, not atrophic.)

Vulvar atypia (formerly leukoplakia) may present as
a slowly progressing, chronic, inflammatory, hypertro-
phic process involving the epidermis and subepithelial
tissues. It may occur as single or multiple discrete

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Plate 6-9 Reproductive System

CIRCULATORY AND
OTHER DISTURBANCES

Varices of the vulva occur most often during pregnancy Varicose veins Angioneurotic edema
or as an aftermath of repeated pregnancies or processes
that increase intraabdominal pressure. They are usually Elephantiasis Hematoma
associated with varicose veins of the lower extremities. blood from minor extravasations is slowly absorbed. trauma from straddle injuries, though sexual abuse,
A primary factor in their development is the presence A hematoma of the vulva that occurs during or rape, and water skiing may also be responsible. Based
of retarded venous flow caused by increased intrapelvic after labor may be of vital significance, because it on the presumed cause, the possibility of an accompa-
or intraabdominal pressure. The veins of the labia may extend paravaginally and pararectally to the sub- nying laceration must always be considered. Analge-
and prepuce are most commonly involved, either uni- peritoneal space and be associated with significant loss sics, pressure, and ice are appropriate initial therapies.
laterally or bilaterally. They may form subcutaneous of circulating blood volume. A large collection of Surgical drainage for rapidly expanding hematomas or
convolutions, which sometimes reach the size of a fist. blood may distend the labia and infiltrate into the those >10 cm in diameter may be required. Most
Subjectively, there may be an annoying “dragging” or ischiorectal fossa and buttock. The most common hematomas gradually resolve with conservative man-
heavy sensation. The varices become prominent when source of vulvar hematomas in young patients is blunt agement only.
the patient is standing and tend to disappear when she
is in the supine position. Those that occur during preg-
nancy are apt to subside, to a great extent, after delivery.
A varix may rupture as a result of direct trauma, injury
during labor, excessive coughing or other straining.
Rarely, a venous thrombosis may ensue. When the
patient is symptomatic, resection, fulguration, sclerosis,
or embolization therapies may be required.

Angioneurotic edema is an allergic reaction, which
may involve the vulva as it does other areas. Its diagno-
sis is suggested by the sudden appearance, without
apparent cause, of a large, noninflammatory, painless
vulvar swelling that is transient. Differentiation should
be made from nephrotic or cardiac edema, or that
which results from increased intrapelvic pressure sec-
ondary to neoplasm or large pelvic exudates. The pos-
sibility of a patent canal of Nuck giving rise to an
inguinal hernia should also be considered. Because of
the loose texture of the subcutaneous tissue of the labia,
marked edematous swelling may accompany small local
infections or contact with allergens. The list of poten-
tial irritants can be extensive, including “feminine
hygiene” sprays, deodorants and deodorant soaps,
tampons or pads (especially those with deodorants or
perfumes), tight-fitting or synthetic undergarments,
colored or scented toilet paper, and laundry soap or
fabric softener residues. Even topical contraceptives,
latex condoms, lubricants, “sexual aids,” or semen may
be the source of irritation. Soiling of the vulva by urine
or feces can also create significant symptoms. Severe
dermatitis of the vulva resulting from contact with
poison ivy or poison oak is occasionally found.

The term elephantiasis is applied to chronic, hyper-
trophic tissue changes secondary to excessive lymph
stasis. In the tropics, the most common cause is a para-
sitic worm, Wuchereria bancrofti. Other diseases, par-
ticularly lymphogranuloma venereum, may cause
obstruction of the lymph channels of the vulva. Histo-
logically, the lymph vessels appear greatly dilated and
the subcutaneous tissue is thickened, edematous, and
inflamed. The surface may be pale, smooth, nodular, or
warty. The labia may be converted into large, pachy-
dermatous, sessile, or pedunculated tumors.

A hematoma of the vulva may be secondary to a fall
or blow, surgical trauma, or rupture of a varix. The

118 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-10 The Vulva

DIABETES, TRICHOMONIASIS,
MONILIASIS

Vulvovaginal infections are a common occurrence and Diabetic vulvitis Trichomoniasis
frequent cause for clinical evaluation. Although most
frequently these are not associated with any underlying Moniliasis These provide active movement. Culture or monoclo-
risk factor, women who are immunocompromised or odoriferous, bubbly discharge may be seen in the ves- nal antibody testing may be obtained but is seldom
have diabetes mellitus are at increased risk for oppor- tibule. Presenting symptoms suggestive of trichomo- necessary. Evaluation for concomitant sexually trans-
tunistic infections such as yeast infections. niasis include a sudden increase in vaginal discharge, missible infections should be strongly considered.
itching about the vulva, a burning sensation as urine Newer technologies have been introduced, resulting in
Even without infection, vulvar itching is a common passes over the inflamed area, and dyspareunia. A wet tests that have a sensitivity greater than 83% and a
occurrence in the diabetic woman. It may persist with mount examination of secretions from the vulva or specificity higher than 97% but require 10 to 45
or without a varying degree of dermatitis secondary to vagina suspended in saline will demonstrate a fusiform minutes to complete. (False positives may occur in low-
scratching. Frequently, a mycotic vulvitis or vulvovagi- protozoon slightly larger than a white blood cell with prevalence populations.)
nitis is superimposed and gives the characteristic picture three to five flagella extending from the narrow end.
of diabetic vulvitis. This is manifested by an inflamed,
dark-red, or beefy appearance, which first involves the
vestibule and labia minora and then spreads to adjacent
parts. The high percentage of sugar in the secretions
bathing the vulva is thought to favor the growth of
various fungi. As a result of irritation, excoriations and
furuncles are common.

Moniliasis is a vaginal infection caused by ubiquitous
fungi found in the air or as common inhabitants of the
vagina, rectum, and mouth. Vulvovaginitis caused by
yeast belonging to the Candida albicans group has been
variously designated as mycotic vaginitis, vulvovagini-
tis, yeast vulvovaginitis, vaginal thrush, or moniliasis.
On speculum examination, white, cheesy, irregular
plaques are found, partially adherent to the congested
mucosa of the vagina and cervix. These are easily wiped
off, sometimes leaving a red margin or shallow ulcer-
ation. The associated vaginal discharge may resemble
curds and whey and may have a characteristic yeasty
odor. The presence of most yeast species elicits a strong
allergic response, resulting in the vestibule and lower
portions of the labia becoming edematous, inflamed,
and covered by minute vesicles, pustules, or ulcerations.
Moniliasis may occur during childhood, sexual matu-
rity, and after the menopause. It has a definite predilec-
tion for pregnant and diabetic women, in whom it may
be particularly resistant to treatment. The diagnosis is
made by the typical clinical appearance and the micro-
scopic demonstration of mycelia and yeast buds in the
wet smear under high dry power. The thread-like
mycelia and conidia may be more apparent after the use
of 10% potassium hydroxide solution or in stained
smears. If further confirmation is desired, a culture may
be made on special culture media. Perineal hygiene
(keeping the perineal area clean and dry, avoiding
tight or synthetic undergarments), education regarding
prevention, and encouraging completion of the pre-
scribed course of antifungal therapy are all appropriate
interventions.

A vaginal infection by the sexually transmitted single-
celled anaerobic flagellate protozoan Trichomonas vagi-
nalis accounts for approximately one-quarter of all
vaginal infections. In the acute stage of trichomoniasis,
a vulvitis is usually also present, as evidenced by conges-
tion of the vestibule and the inner aspects of the labia
minora. On separating the inflamed labia, a thick,

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 119

Plate 6-11 Reproductive System

Vulvar vestibulitis is syndrome of intense sensitivity of skin
of posterior vaginal introitus and vulvar vestibule resulting
in dyspareunia and pain on attempted use of tampons.

Area most commonly involved is posterior
to Bartholin glands.
Opening of minor vestibular glands
Orifice of Bartholin gland
Bartholin gland

VULVAR VESTIBULITIS

Vulvar vestibulitis is an uncommon syndrome of intense Level of discomfort is usually out Hymenal ring
sensitivity of the skin of the posterior vaginal introitus of proportion to degree of physical
and vulvar vestibule, characterized by progressive wors- findings, which include 1 to 10 Bartholin gland opening may be inflamed
ening, which leads to dyspareunia, vulvodynia, and loss small (3–10 mm) areas of punctate
of sexual function. Some estimates place its prevalence inflammation, some with ulceration Punctate erosions on erythematous
at 15% of all women, but significant, disabling symp- in perineal and vaginal epithelium base found in vestibule and introitus
toms are much less common. Although the median age
of occurrence is 36 years, it can occur at any time after Involved area may be demarcated by hydrochloride), which may reduce pain and itch. Inter-
the late teenage years. New onset of symptoms is light touch with cotton-tipped applicator feron injections may provide relief in up to 60% of
uncommon after menopause. patients but cannot be used in women who are preg-
Magnified view of vestibule nant. (Patients should be warned that interferon injec-
The cause of vestibular vestibulitis is unknown but tions are associated with flu-like symptoms and a
there does appear to be a high degree of association Initial management includes general perineal clinical response may not be seen for up to 3 months.
with human papillomavirus, though no causal link has hygiene, cool sitz baths, moist soaks, or the application Patients should abstain from intercourse during the
been established. It has been postulated that the use of of soothing solutions such as Burow’s solution (alumi- series of injections.) Refractory disease may require sur-
oral contraceptives may increase the risk or severity of num acetate, 1 : 40 solution). Patients should be advised gical resection or laser ablation. Surgical therapy is
vulvar vestibulitis and that patients with vulvar vestibu- to wear loose-fitting clothing and keep the area dry and associated with 50% to 60% success rates.
litis should switch to other methods of contraception. well ventilated. Spontaneous remission may occur in
Strong evidence for either causation or significant one-third of patients over the course of 6 months.
improvement is lacking. Despite the implication of the
term, widespread true inflammation is not a character- More specific suggestions include topical anesthetics
istic of this process. (lidocaine [Xylocaine] 2% jelly [or 5% cream] as
needed or overnight) and antidepressants (amitriptyline
The most common symptom is intense pain and ten-
derness at the posterior introitus and vestibule, most
often present for 2 to 5 years. (Some authors suggest
that symptoms must be present for more than 6 months
before the diagnosis is made.) Most patients are unable
to use tampons (33%) or to have intercourse (entry
dyspareunia, 100%). The appearance of focal inflam-
mation, punctation, and ulceration of the perineal and
vaginal epithelium is common.

On physical examination, punctate areas (1 to 10) of
inflammation 3 to 10 mm in size may be seen between
the Bartholin glands, hymenal ring, and middle
perineum. Colposcopy of the vulva (using 3% acetic
acid) may reveal the characteristic small inflammatory
punctate lesions varying in size from 3 to 10 mm, often
with superficial ulceration and acetowhite areas. The
Bartholin gland openings may be inflamed as well. The
area involved may be demarcated by light touching
with a cotton-tipped applicator, although the level of
discomfort is often out of proportion to the physical
findings. If a biopsy is performed (not necessary for
diagnosis), inflammation of minor vestibular glands
may be seen.

Vulvar vestibulitis must be differentiated from cases
of vaginismus, chronic or atrophic vulvitis, hypertro-
phic vulvar dystrophy, and other vulvar dermatoses,
including contact (allergic) dermatitis.

120 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-12 The Vulva

GONORRHEA

The symptoms of acute gonorrhea of the vulva may Acute urethritis and skenitis Bartholin abscess
appear from 1 day to several days after contact, are
often mild or transitory, and may be overlooked. The Chronic urethritis with Vulvovaginitis of childhood
patient may experience burning on urination, urinary infection of urethral glands
frequency, leukorrhea, and itching in the vestibule. urethra and anus, although these additional cultures do
Occasionally, however, the first suggestive manifesta- Chronic skenitis not significantly increase the sensitivity of testing. A
tion of disease is not apparent until the following discharge. The profuse leukorrhea results in secondary Gram stain of any cervical discharge for the presence
menses or shortly thereafter, when the ascending infec- irritation of the labia and perineum. The adult vaginal of gram-negative intracellular diplococcus supports
tion has resulted in an acute salpingitis. Examination of mucosa, by virtue of its thickness and acidic environ- the presumptive diagnosis but does not establish it
the external genitalia may reveal a congested vestibule ment, is more resistant to the gonococcus, but in child- (sensitivity 50% to 70%, specificity 97%). A solid-phase
bathed in pus and an inflammation of the urethra and hood and after menopause the vagina is far more enzyme immunoassay may also be used. Even when the
Skene and Bartholin ducts. The acute infection ascends susceptible to infection because of its thin epithelial diagnosis is established by other methods, all cases of
via the mucosa and epithelium of the urogenital tract layer and its alkaline environment. gonorrhea should have cultures obtained to assess anti-
and may give rise to an endometritis, peritonitis (pelvic biotic susceptibility, although therapy should not be
inflammatory disease), and tuboovarian abscess. By Culture on Thayer-Martin agar plates kept in a CO2- delayed pending the results.
lymphatic absorption and hematogenous spread, it may rich environment may be used to document the infec-
result in septicemia, endocarditis, arthritis and tenosy- tion. Cervical cultures provide 80% to 95% diagnostic
novitis. Although if untreated, gonorrheal infection sensitivity. Cultures should also be obtained from the
may, at times, be uncomplicated and self-limited, the
tendency for establishment of deep-seated chronic foci
is strong. These occur particularly within compound
tubular glands and structures lined by columnar epithe-
lium, such as the periurethral and Bartholin glands and
the endocervix.

In acute urethritis, the mucosa of the external ure-
thral meatus is reddened and edematous. On gentle
stripping of the urethra, a few drops of thick yellow pus
escape. The inflammatory reaction results in urinary
frequency, urgency, and dysuria.

Acute skenitis is evident in the swollen, slightly
raised, injected ostia of Skene ducts, which expel pus
when milked. The ducts may harbor gonorrheal organ-
isms over long periods of time. Thickened ducts and
conspicuous orifices from which beads of pus can be
expressed suggest a chronic infection.

In acute bartholinitis, the openings of the Bartholin
ducts, normally inconspicuous, become more apparent
because of the surrounding inflammation. On palpa-
tion, the Bartholin gland may be enlarged and tender.
The infection can progress rapidly, resulting in an
extremely painful swelling of the lower half of the
labia. Eventually, a tender, red fluctuant abscess may
develop, with taut, congested overlying skin, edema of
the labia, and regional lymphadenopathy. This abscess
may persist or may lead to a chronic infection, evi-
denced by enlargement of the gland, recurrent abscesses,
and cyst formation.

Chronic urethritis may be manifested by a palpable
induration of the posterior urethral wall mainly due to
a persistence of infection within the shallow posterior
urethral glands, seen endoscopically as small granular
areas on the urethral floor. The only symptom may be
a burning sensation on urination.

In vulvovaginitis of childhood gonorrhea, the vagina
and the vestibule of the vulva are inflamed and edema-
tous and are covered by a creamy, yellow-green

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 121

Plate 6-13 Reproductive System

SYPHILIS

Syphilis presents with an easily overlooked first stage Chancre with inguinal adenopathy
and, if left untreated, can slowly progress to a disabling
disease noted for central nervous system, cardiac, and Condylomata lata
musculoskeletal involvement. The primary lesion of
syphilis, though readily noted by the male, is not infre- The moisture, warmth, and irritation of the opposing Condylomata lata may cover the vulva, perineum, peri-
quently overlooked by the female. It appears most com- surfaces of the vulva tend to modify the papules of sec- anal region, inner thighs, and buttocks and grow during
monly on the labia majora, mons veneris, clitoris, ondary syphilis, which appear in this region. Through pregnancy. The lesions are highly infectious.
fourchette, and vaginal mucosa but can also be seen on coalescence, hypertrophy, maceration, and ulceration,
the anus, rectum, pharynx, tongue, lips, fingers, or the the typical condylomata (moist papules, syphilitic warts) Ulcerated and hypertrophic gummas of the vulva, as
skin of almost any part of the body. The initial lesions are produced. These appear as multiple, slightly ele- manifestations of tertiary syphilis, are rare. They are
first appear 10 to 60 days (average, 21 days) after infec- vated, disc-shaped, round or oval lesions, of sizes varying firm, massive growths, which may extend deeply into
tion as a fissure, abrasion, or nodule with slight erosion up to that of a dime. They are often confluent or in clus- underlying tissues or may appear as multinodular ulcer-
and may then develop the characteristics of a hunterian ters, with a moist, slightly depressed, necrotic surface. ated tumors involving part or most of the vulva. Sec-
chancre; an orange-red, granular ulcer, round or oval ondary infections are common.
in shape, 1 or 2 cm in diameter, with sharp margins,
and an indurated base. Multiple chancres are sometimes
seen, particularly within the labial folds.

Inguinal lymphadenopathy begins slowly, and by the
sixth week after infection is usually well delineated. It
appears as firm, painless, nonsuppurating nodes, from
the size of a cherry to that of a walnut. Histologically,
the chancre shows edema, congestion, and infiltration
with lymphocytes, plasma cells, epithelioid, and giant
cells. The initial lesions heal and may be associated with
progression to a low-grade fever, headache, malaise,
sore throat, anorexia, generalized lymphadenopathy,
and a diffuse, symmetric, asymptomatic maculopapular
rash over the palm and soles (“money palms”), mucous
patches, and condyloma lata.

The Venereal Disease Research Laboratory (VDRL)
and rapid plasma reagin (RPR) tests are nonspecific
tests that are good screening tests because they are
rapid and inexpensive. The fluorescent treponemal
antibody absorption or microhemagglutination Trepo-
nema pallidum tests are specific treponemal antibody
tests that are confirmatory or diagnostic and are gener-
ally not used for routine screening. Rather, they are
useful to rule out a false-positive screening test, though
reductions in the cost of these tests may change this role
to one of screening as well. False-positive screening
results may occur in patients with lupus, hepatitis, sar-
coidosis, recent immunization, drug abuse, or during
pregnancy. These test results may be falsely negative in
the second stage of the disease as a result of high levels
of anticardiolipin antibody that interferes with the test
(prozone phenomenon). Up to 30% of patients with a
primary lesion have negative test results. (Approxi-
mately 15% to 25% of patients treated during the
primary stage revert to being serologically nonreactive
after 2 to 3 years.) If neurosyphilis is suspected, a
lumbar puncture with a VDRL performed on the spinal
fluid is required. (Unless clinical signs or symptoms of
neurologic or ophthalmic involvement are present,
cerebrospinal fluid (CSF) analysis is not recommended
for routine evaluation of patients who have primary or
secondary syphilis.) Screening for HIV infection should
also be strongly considered.

122 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-14 The Vulva

Chancroid

CHANCROID AND
OTHER INFECTIONS

Infection by Haemophilus ducreyi results in chancroid, Lymphogranuloma venereum the groin, inner thigh, perianal region, and buttock.
one of a group of infrequently encountered sexually The characteristic picture is that of a red, exuberant,
transmitted infections. Chancroid is more common Granuloma inguinale granulomatous surface, with well-defined serpiginous
than syphilis in some areas of Africa and Southeast Asia margins. The “pseudobubo” sometimes seen is usually
but uncommon in the United States. After incubation per year in the United States. This infection is caused a subcutaneous granuloma. Healing occurs slowly, the
of 3 to 10 days, a papule or pustule, surrounded by a by the intracellular gram-negative bacterium Klebsiella lesion persisting for many months or years. The diag-
vivid areola of inflammation, may be noted within the granulomatis (formerly known as Calymmatobacterium nosis is established by the appearance of the typical
vestibule, at the fourchette or on the labia minora. This granulomatis). The incubation period varies. The lesions and by demonstration of Donovan bodies in
develops into one or more typical “soft chancres.” The primary lesion may be seen as a vivid, circumscribed, surface smears or biopsies. Chancroid, syphilis, tuber-
chancroid appears as a pinkish-red, granular ulcer with granulomatous nodule on the vulva, vaginal mucosa, culosis, and carcinoma must be excluded in the differ-
punched-out, uneven, undermined edges and a necrotic, cervix, or in such extragenital sites as the face or neck. ential diagnosis.
purulent floor. The ulceration is painful and destructive The initial lesion spreads by peripheral extension rather
and lacks the characteristic induration seen in the than through the lymphatics. The skin and mucous
primary chancre of syphilis. Suppurative inguinal nodes membranes are primarily involved. The disease does
or “buboes” are common. The combination of a painful not penetrate deeply but may gradually extend to
ulcer and tender inguinal adenopathy suggests chan-
croid; when accompanied by suppurative inguinal ade-
nopathy, they are almost pathognomonic. A definitive
diagnosis of chancroid requires identification of H.
ducreyi on special culture media that are not widely
available; even using these media, sensitivity is 80% or
less. Gram stain of material from open ulcers can also
be confirmatory.

Lymphogranuloma venereum is caused by one of a
number of serotypes (L-1, L-2, L-3) of Chlamydia tra-
chomatis. Although uncommon in the United States,
this infection causes significant morbidity. The initial
lesion appears a few days after exposure as a papule,
pustule, or erosion on the vulva or within the vagina. It
is of short duration, inconspicuous, and, therefore,
almost always overlooked. Within 1 to 3 weeks, the
tendency toward lymphatic spread becomes evident in
the slow development of inguinal adenitis progressing
until a painful, matted mass of glands is present, with
periadenitis and occasional suppuration and draining
sinuses. The extent and severity of inguinal lymphad-
enitis in the female are less than in the male. When the
pelvic and perirectal lymphatics become involved, rectal
stricture may result from progressive inflammation and
ulceration about the entire circumference of the rectum,
with subsequent fibrosis and cicatrization. At times,
hypertrophic changes with extensive infiltration and
ulceration may involve the vulva, vagina, urethra, and
perineum. The destructive process may give rise to
fistulae, and blockage of lymph channels may cause
elephantiasis. The lymph node pathology is that of a
granuloma with multiple abscesses and masses of epi-
thelioid and giant cells. Diagnosis is by complement
fixation testing—80% of patients have a titer of 1 : 16
or greater. Genital and lymph node specimens (i.e.,
lesion swab or bubo aspirate) may be tested for C. tra-
chomatis by culture, direct immunofluorescence, or
nucleic acid detection.

Granuloma inguinale (also called donovanosis) is
relatively common in the tropics, New Guinea, and
Caribbean areas, but accounts for less than 100 cases

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 123

Plate 6-15 Reproductive System

CYSTS

A Bartholin cyst results from the occlusion of the excre- Bartholin cyst Sebaceous cyst
tory duct or one of its subdivisions. Etiologic factors
include specific or nonspecific infections and accidental Inclusion cyst Cyst of canal of Nuck
or operative trauma. Most often an infection in one or A cyst of the canal of Nuck refers to a cystic dilation
both Bartholin glands results in swelling and/or abscess becomes tense, red, swollen, tender and painful, resem- of an unobliterated peritoneal pouch, the analogue to the
formation. Usually the acute process is unilateral and bling a furuncle. processus vaginalis in the male. This may extend for a
marked by pain and swelling. Systemic symptoms are varying distance along the round ligament, which this
minimal except in advanced cases. Once the acute infec- Inclusion cysts are sometimes noted in the perineum, pouch accompanies during fetal life. The cyst may develop
tion has passed, stenosis and scarring of the duct may at the fourchette, and within the vagina. They are in the upper half of the labium majus with a pedicle
result in the formation of a chronic cyst. usually quite small, varying in size from a pea to a leading into the inguinal canal. An excised specimen may
walnut. They may result as an aftermath of a reparative present a wall composed of fibrous and muscular tissue.
The cyst appears as fluctuant swelling in the poste- operation for perineal laceration. When a portion of A lining epithelium of low cuboidal or cylindrical cells
rior aspect of the labia. When palpated between the epithelium is buried beneath the surface, it usually (persistent endothelium) may or may not be present.
thumb and index fingers, it is quite movable beneath becomes encysted, with an accumulation of desqua-
the overlying skin. The cysts may be clear, yellow or mated and degenerated epithelium.
bluish in color, and the size may vary from that of a
marble to that of a large egg. Unless secondarily
infected, they cause little or no discomfort. (More than
80% of cultures of material from Bartholin gland cysts
are sterile.) The contents of the cyst are usually clear
and mucoid. Microscopic examination usually reveals
evidence of the transitional cell epithelium, derived
from the duct wall, and Bartholin gland tissue. The cyst
lining is usually transitional epithelium, but the patho-
logic diagnosis is made by the additional presence of
compound mucinous glands in the wall.

Asymptomatic cysts in women below the age of 40
do not need treatment. (Above this age, biopsy is indi-
cated.) Excision of the gland is often difficult and is
associated with significant risk of morbidity, including
intraoperative hemorrhage, hematoma formation, sec-
ondary infection, scar formation, and dyspareunia.
Therefore, excision is not generally recommended.
When treatment must be instituted, marsupialization of
the cyst is usually the best course: A 1- to 2-cm vertical
or “stab” incision is made, usually within the hymenal
ring; sutures are generally not required. A Word cath-
eter should then be placed through the incision and
inflated with a few milliliters of saline. The catheter is
left in place for 6 weeks. As an alternative, iodoform
gauze packing may be placed within the cavity with a
2- to 3-cm tail left outside the incision to facilitate
eventual removal. Unless cellulitis is present, antibiotic
therapy is not required.

The labia majora and minora contain numerous seba-
ceous glands. When occlusion of a duct occurs, a cystic
enlargement may result from retention within the gland
of sebum and epithelial debris. Sebaceous cysts are
usually small but may reach the size of a walnut. They
may be single or multiple. They are moderately firm,
quite movable, and may be asymptomatic when unin-
fected. When secondary infection occurs, the cyst

124 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-16 The Vulva

BENIGN TUMORS

Benign tumors of the vulva include the fibroma, fibro- Condylomata acuminata
myoma, lipoma, papilloma, condyloma acuminatum,
urethral caruncle, hidradenoma, angioma, myxoma, Lipoma Fibroma
neuroma, and rarely endometrioid growths.
Hidradenoma Urethral caruncle
Condylomata acuminata are a form of papilloma
commonly known as venereal warts. These are caused frequency and dysuria. Because of the associated vascu- entire circumference of the urethral mucosa is seen to
by several serotypes (most frequently serotypes 6 and larity, edema, and inflammatory reaction, bleeding protrude through the external meatus, similar to that
11; 90%) of the human papilloma virus. This DNA occurs readily. Repeated or chronic infections of the seen in prolapse of the rectal mucosa through the anus.
virus is found in 2% to 4% of all women, and up to urethra or bladder may predispose toward the develop- Congestion and edema are marked. Localized throm-
60% of patients have evidence of the virus when poly- ment of a caruncle. It is important to discriminate a bosis and necrosis may occur, accompanied by severe
merase chain reaction techniques are used. The virus is caruncle from patulous or simple eversion of the exter- bleeding. A small carcinoma of the urethra may simu-
hardy and may resist even drying, making transmission nal urethral meatus, prolapse of the urethral mucosa, late or be superimposed upon a urethral caruncle.
and autoinoculation common. There is some evidence and localized carcinoma of the urethra. Urethral pro- Errors in diagnosis may be avoided by biopsy or exci-
that fomite transmission could rarely occur. The virus lapse occurs most commonly in elderly women. The sion instead of destruction by cauterization.
is most commonly spread by skin-to-skin (generally
sexual) contact and has an incubation period of 3 weeks
to 8 months, with an average of 3 months. Roughly
65% of patients acquire the infection after intercourse
with an infected partner. The papillomas usually appear
as multiple, soft, pointed, warty excrescences about the
labia and perineum. When numerous, they may give
rise to a confluent, cauliflower-like growth. Histologi-
cally, they present a central stroma of congested and
infiltrated connective tissue covered by hypertrophied,
stratified squamous epithelium with deep papillary pro-
jections and a thick, superficial, cornified zone.

Fibromas arising from the connective tissue of the
vulva are usually small to moderate in size. They tend
to become pedunculated as they increase in size and
weight. Their consistency depends in part on the
degree of edema due to degeneration or deficiency of
the circulation. They may originate from the region
of the round ligament or the deeper pelvic structures
and present themselves at the vulva. Occasionally,
microscopic section reveals an apparent fibroma to be
a fibromyoma. Sarcomatous changes may occur, though
rarely.

Lipomas of the vulva are less common than fibromas.
They are softer and have a more homogeneous consis-
tency. They may occasionally reach large proportions.

The hidradenoma is a benign, relatively rare tumor
of sweat gland origin. It appears usually as a small
nodule on the labium majus or in the interlabial sulcus.
The skin over the surface of the tumor may ulcerate
and bleed, giving rise to a grayish or red fungating
tumor, sometimes mistaken for carcinoma. Histologi-
cally, the hidradenoma or sweat gland adenoma pres-
ents an edematous, tubular structure lined by nonciliated
columnar cells with clear cytoplasm and dark-staining
nuclei. In the smaller acini, cuboidal or rounded cells
may be evident. Cystic changes and intracystic papillary
proliferations are not infrequent.

Urethral caruncles are pedunculated or sessile, small
to pea-sized, bright-red growths projecting from the
posterior edge of the urethral meatus. They may be
granulomatous, angiomatous, or telangiectatic. They
are extremely sensitive and often give rise to urinary

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 125

Plate 6-17 Reproductive System

MALIGNANT TUMORS

About 5% of the malignant tumors of the female genital Carcinoma of the clitoris Carcinoma on leukoplakia
organs originate on the vulva. (The incidence of vulvar
cancer rose by approximately 20% between 1973 and Sarcoma of the labium Metastatic hypernephroma
2000, likely related to increased exposure to human metastases from a hypernephroma of the kidney, cho-
papillomavirus [HPV].) Primary carcinoma is almost cell carcinomas. A rodent ulcer or superficial erythema- rioepithelioma of the uterus, and carcinoma of the
always seen in elderly women with an average age for tous type may be seen. Definite connections with other uterine body or cervix. At times, the vulvar lesion may
in situ tumors being 40 to 49 years, and 65 to 70 for diseases or predisposing factors, such as leukoplakia or be the first indication of the existence of a primary
invasive lesions. The vast majority of these tumors are hypertrophic venereal lesions, have not been estab- carcinoma elsewhere.
of the squamous cell variety. Histologic types include lished. The neoplasms are slow-growing and radiosensi-
squamous cell (90%), melanoma (5%), basaloid, warty, tive. Regional metastases are rare, but local extension Sarcoma of the vulva is infrequent. Varieties include
verrucous, giant cell, spindle cell, acantholytic squa- and recurrence are characteristic. Wide local excision fibrosarcoma, spindle-cell sarcoma, lymphosarcoma,
mous cell (adenoid squamous), lymphoepithelioma- may suffice instead of the more radical vulvectomy and myxosarcoma, liposarcoma, round cell, giant cell, and
like, basal cell, and Merkel cell. Sarcoma accounts for bilateral femoral and pelvic lymphadenectomy. polymorphous cell sarcoma. These are usually very
approximately 2% of vulvar cancers. Metastatic tumors aggressive in character. Occasionally, their malignancy
from other sources are rare but do occur. Secondary carcinoma of the vulva (metastatic to) is may be of low grade.
uncommon but may occur. This is particularly true of
Squamous cell cancer of the vulva generally presents
as an exophytic ulcer or hyperkeratotic plaque. It may
arise as a solitary lesion or develop hidden within
hypertrophic or other vulvar skin changes, making
diagnosis difficult and often delayed. Known or sus-
pected risk factors include infection with human papil-
lomavirus (molecular analysis had detected HPV DNA
in 40% of vulvar cancers), smoking, immunosuppres-
sion, and lichen sclerosus.

Occasionally, adenocarcinoma may develop from
Bartholin gland, mucous glands, or sweat glands. Rarely,
a medullary carcinoma may be seen. The sites of origin,
in the order of their frequency, are the labia majora,
prepuce of the clitoris, labia minora, Bartholin gland,
posterior commissure, and urethral area.

Leukoplakia and venereal granulomatous lesions
appear to be predisposing factors in the development of
vulvar malignancy. It is estimated that about 50% of
primary carcinomas are preceded by leukoplakia. The
initial lesion may be a small, firm nodule or thickening,
with slow but progressive enlargement, infiltration and,
finally, ulceration. The early symptoms may be insig-
nificant, consisting merely of soreness and pruritus. In
the neglected case the tumor may become large,
nodular, hypertrophic, ulcerated, and foul smelling.
Additional prevailing complaints may then include a
purulent, odoriferous leukorrhea and local irritation
following urination. Lymphatic extension to the
regional inguinal nodes occurs early and in a high per-
centage of cases. Distant metastases are rare. However,
because pulmonary involvement is occasionally encoun-
tered, a routine x-ray examination of the chest is war-
ranted. Because of neglect and lack of recognition, the
average case is not brought to operation until about 1
year after the onset of symptoms.

Basal cell carcinoma of the vulva is relatively uncom-
mon. A variable incidence of 1.2% to 13% of the epi-
dermoid carcinomas has been reported. Basal cell
carcinoma of the vulva is to be differentiated from the
squamous cell variety. The age of appearance, the signs,
and the symptoms are similar to those of early squamous

126 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 6-18 The Vulva

Clitoris and
prepuce removed

Clitoris and portion
of labia minora excised

FEMALE CIRCUMCISION

Female circumcision is a culturally determined practice Type I: Clitoridectomy Type II: Clitoridectomy and
of ritually cutting a female’s external genitals that partial excision of labia minora
results in removal of part or all of the external genitalia Total excision of clitoris
including the labia majora, labia minora, and/or the and labia minora Incisions in labia majora for
clitoris. This activity is illegal in many locations. Female approximation over urethra and
circumcision (female genital mutilation, infibulation) is vaginal entrance (infibulation)
generally performed as a ritual process, often without
benefit of anesthesia and frequently under unsterile Excision of clitoris and labia minora and
conditions, generally near the time of puberty or incision of labia majora in types III and IV
soon after. The resulting scarring may preclude intro-
mission or normal vaginal delivery should pregnancy be Anterior two thirds of labia majora
achieved. In rare cases, scarring and deformity may be closed over urethra and vaginal entrance
sufficient to result in amenorrhea or dysmenorrhea.
The ritual is often performed to reinforce a woman’s Majority of labia majora
place in her society, to establish eligibility for marriage approximated over urethra
and entry into womanhood. It is sometimes also and vaginal entrance
performed to safeguard virginity or to paradoxically
improve fertility. Although the ritual can have devastat- Opening Type IV: Total infibulation—allows
ing effects on the woman’s sexual pleasure, it is some- Opening only small posterior opening for
times performed to enhance the husband’s pleasure. urine and menstrual flow
Type III: Modified (intermediate infibulation)
The amount and location of tissue removed deter- —allows moderate posterior opening
mine the type of infibulation:
activity may also present medical complications for the sexual function. An anterior episiotomy, with or without
Type I—excision of the prepuce, with or without infibulated woman. For example, if her narrow introitus subsequent repair, may be required at the time of child-
excision of part of or the entire clitoris. tears “naturally” (by penile penetration), local infec- birth. (Subsequent repair of the episiotomy is illegal
tions and laceration of adjacent tissues may occur, in some locations, such as the United Kingdom and
Type II—excision of the clitoris with partial or total leading to possible further complications. Increasingly, others, because this amounts to reinfibulation.) Sexual
excision of the labia minora. (This is the most women are consulting physicians prior to initiating sequelae are often lifelong despite surgical revision
common form.) sexual activity and requesting deinfibulation. (especially when clitoridectomy has been performed).
Care for these women must be provided in a nurturing,
Type III—excision of part or all of the external Surgical opening of fused or scarred genital tissue nonjudgmental way.
genitalia and stitching/narrowing of the vaginal may be necessary to allow for menstrual hygiene and
opening (infibulation).

Type IV—pricking, piercing, or incising of the clito-
ris and/or labia; stretching of the clitoris and/or
labia; cauterization by burning of the clitoris and
surrounding tissue.

Other forms of female genital mutilation include the
following:

Scraping of the tissue surrounding the vaginal orifice
(angurya cuts) or cutting of the vagina (gishiri cuts)
or the introduction of corrosive substances or
herbs into the vagina to cause bleeding or for the
purpose of tightening or narrowing the vagina.

It has been estimated that more than 130 million
women worldwide have undergone some form of
female circumcision. Although uncommon in the
United States (estimated to be 168,000 in the United
States, with 48,000 younger than 18 years), more than
95% of women in some countries (e.g., Somalia) have
had one of these procedures.

These patients may experience bleeding and infec-
tion (including tetanus), urinary retention, and pain at
the time of the original procedure. Long term, the
patient may experience sexual dysfunction, difficulty
with menstrual hygiene, recurrent vaginal or urinary
tract infections, retrograde menstruation, hematocol-
pos, or chronic pelvic inflammatory disease. Excessive
scarring, including keloid formation, adhesions, and
pelvic and back pain are all common. Initiation of sexual

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SECTION 7

THE VAGINA

Plate 7-1 Reproductive System

Paramedian (sagittal) dissection

THE VAGINA Ureter Rectouterine
Uterine pouch
The vagina (from Latin, literally “sheath” or “scab- (fallopian) (of Douglas)
bard”) serves as the portal to the internal female repro- tube
ductive tract and a route of egress for the fetus during Ovary Peritoneum
delivery. The viscera contained within the female pelvis Ligament (cut edge)
minor include the pelvic colon, urinary bladder and of ovary
urethra, uterus, uterine tubes, ovaries, and vagina. Round Vesicouterine
These structures surround the vagina and interact with ligament pouch
it in the clinical setting. Therefore, the vagina also of uterus Rectum
provides a convenient portal to understanding the Broad Ureter
female pelvic viscera. ligament (cut) Urinary
Superior pubic bladder
The vagina is a thin-walled, distensible, fibromuscu- ramus (cut) Vagina
lar canal, covered by specialized epithelium, which Inferior pubic
extends from the vulva inward to the cervix and uterus. ramus (cut) Pelvic diaphragm
Under normal circumstances, the vagina is a potential Ischiocavernosus (levator ani muscle)
space that is larger in the middle and upper thirds, muscle
giving it an inverted pear- or T-shape when viewed Body of clitoris External anal
perpendicular to its long axis. The walls of the vagina Labia sphincter muscle
are normally flattened in the anteroposterior diameter, minora Deep transverse
giving the appearance of the letter H in cross section. Labium perineal muscle
majus (cut)
In its distal extreme, the vagina opens to the vulva at
the hymenal ring, opening at the caudal end of the Deep perineal space Dorsal artery of clitoris
vulva, behind the opening of the urethra. When upright, Dorsal nerve of clitoris
the vaginal tube points in an upward–backward direc- Deep dorsal vein of clitoris Deep artery of clitoris
tion with the axis of the upper portion of the vagina in Compressor
close to the horizontal plane, curving toward the hollow External urethral orifice urethrae muscle
of the sacrum. In most women, an angle of at least 90°
is formed between the vagina and the uterus. The cervix Perineal membrane Artery to bulb
is directed downward and backward to rest against the (cut and deflected) of vestibule
posterior vaginal wall. The spaces between the cervix Cut edge of superficial
and attachment of the vagina are called fornices, with perineal (Colles) fascia Internal pudendal
the posterior fornix considerably larger than the ante- Vaginal orifice (clitoral) artery
rior fornix.
Greater vestibular Vaginal Deep and superficial
Although there is wide variation, the length of the (Bartholin) glands wall branches of perineal
vagina is approximately 6 to 9 cm (2.5 to 3.5 in.) along nerve (cut)
the anterior wall and 8 to 12 cm (3 to 4.5 in.) along the the lower portion of the cardinal ligaments support
posterior wall. During sexual arousal, the upper portion the middle third of the vagina, whereas portions of the Deep transverse
of the vagina elongates and widens through a relative cardinal ligaments and the parametria support the perineal muscle
upward movement of the uterus and cervix. This is upper third.
thought to facilitate capture and retention of sperm to arteries. There is an anastomosis with the descending
enhance the chance of conception. The vagina is supplied by an extensive anastomotic cervical branch of the uterine artery to form the azygos
network of vessels that surround its length. The vaginal arteries. Branches of the internal pudendal, inferior
Throughout most of its length, the vagina lies artery originates either directly from the uterine artery vesical, and middle hemorrhoidal arteries also contrib-
directly on top of the descending rectum, separated by or as a branch of the internal iliac artery arising poste- ute to the interconnecting network from below. These
the rectovaginal septum. The upper one-fourth of the rior to the origin of the uterine and inferior vesical can be a significant source of bleeding with obstetric
vagina is separated from the rectum by the rectouterine lacerations. They are also important in the develop-
pouch (posterior cul-de-sac). The urethra and base of ment of vaginal transudate during sexual arousal, when
the urinary bladder lie above the anterior vaginal wall the vagina produces lubrication to aid in penetration.
separated by the thin layers of endopelvic fascia. As they
enter the bladder, the ureters pass forward and medial-
ward close to the lateral fornices.

The vagina is held in position by the surrounding
endopelvic fascia and ligaments: The lower third of the
vagina is surrounded and supported by the urogenital
and pelvic diaphragms. The levator ani muscles and

130 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 7-2 The Vagina

PELVIC DIAPHRAGM I— Inferior view Musculofascial extensions to urethra
FROM BELOW
Pubic symphysis Musculofascial extensions to vagina
Removing the superficial muscles and fasciae of the
pelvic floor, the pelvic diaphragm, viewed from below, Inferior (arcuate) Interdigitating fibers of perineum
forms a hammock of muscle from the pelvic brim, pubic ligament
investing the urethra, vagina, and rectum and attaching Puborectalis muscle
posteriorly to the sacrum and coccyx. The principal Inferior pubic (part of levator ani muscle)
muscles of this group are the levatores ani, consisting ramus
of both medial and lateral components on each side and Pubococcygeus muscle
supplied by the pudendal nerve. The larger medial Deep dorsal (part of levator ani muscle)
component, the pubococcygeus, arises from the poste- vein of clitoris
rior surface of the superior ramus of the pubis adjacent Tendinous arch of
to the symphysis, whence the fibers pass downward and Urethra levator ani muscle
backward around the lateral walls of the vagina, with
some fibers reaching the coccyx, some terminating in Vagina Obturator internus muscle
the fascia forming the central tendinous point of the
perineum, and others blending with the longitudinal Rectum Iliococcygeus muscle
muscle coats of the rectum. The pubococcygei are sepa- (part of levator
rated medially by the interlevator cleft through which Ischial spine Sacrum Tip of coccyx ani muscle)
pass the dorsal vein of the clitoris, the urethra, vagina,
and rectum. These organs are supported by musculo- (Ischio-)coccygeus Ischial tuberosity
fascial extensions from the pubococcygei, their inferior muscle
fascia being continuous with the superior fascia of the Obturator internus
urogenital diaphragm. Piriformis muscle (cut) tendon

The lateral component of the levatores ani, the ilio- Sacrospinous ligament (cut) Ischial spine
coccygeus, arises from the ischial spine and from the
tendinous arch, a condensation of the parietal pelvic Sacrotuberous ligament (cut) Sacrospinous ligament
fascia covering the inner surface of the obturator inter-
nus muscle, which extends from the posterior surface Piriformis muscle
of the pubis to the spine of the ischium. The iliococ-
cygeus inserts in the last two segments of the coccyx, Sacrotuberous ligament
but some elements cross the midline anterior to the
coccyx to unite with those from the opposite side in a Levator plate (median raphe)
raphe, where they are joined at a more superficial level of levator ani muscle
by fibers from the sphincter ani externus and the trans-
verse perineal muscles. Anococcygeal body (ligament)
(attachment of external
Posteriorly, the main pelvic diaphragm is nearly anal sphincter muscle)
completed by the triangular coccygeus muscle. The
apex of the coccygeus is attached to the spine of the Lateral view Piriformis muscle Greater sciatic foramen
ischium and the sacrospinous ligament, which it directly Sacrotuberous ligament (cut)
overlies; the base is attached to the lower portion of the Ischial spine
lateral sacrum and the coccyx. This is best seen in the Median sacral crest
lateral view. In addition to supporting the pelvic viscera, Iliococcygeus muscle
the muscles of the pelvic diaphragm aid in the constric- 4th posterior (dorsal) (part of levator ani muscle)
tion of the vagina during coitus, in parturition, micturi- sacral foramen
tion, and in defecation. The obturator internus and Tendinous arch of
piriformis muscles round out the posterior pelvis before (Ischio-)coccygeus muscle levator ani muscle
passing through the lesser and greater sciatic foramina,
respectively, to insert on the femur. These muscles lie Sacrospinous ligament (cut) Pubococcygeus muscle
close to the lateral walls of the pelvis. (part of levator ani muscle)
Coccyx
The obturator internus arises from the circumfer- Puborectalis muscle
ence of the obturator fossa by fibrous attachments Anococcygeal body (ligament) (part of levator ani muscle)
(attachment of external
anal sphincter muscle) Rectum Pubic bone
(cut surface)

Deep dorsal vein
of clitoris

Urethra

Vagina

directly to the bone and, to a lesser extent, from the sacrotuberous ligament, with its fibers covering a large
obturator membrane, the tendinous arch, and the obtu- part of the greater sciatic notch, through which it passes
rator fascia, which covers the inner surface of the out of the pelvis to attach in the superior portion of the
muscle. The fibers pass downward and backward, greater trochanter of the femur. The piriformis is sup-
forming tendinous bands as they near the lesser sciatic plied by sacral nerves 1 and 2; the obturator internus
notch and then, passing through this notch, they insert by sacral nerves 1, 2, and 3. They aid in external rota-
outside the pelvis on the medial surface of the greater tion and abduction of the hip and are not directly con-
trochanter of the femur. cerned with support of the pelvic floor. However, the
fascia covering these muscles is continuous with the
The piriformis, best seen in the lateral view, arises pelvic diaphragm and with the endopelvic fascia.
from the lower portion of the sacrum and the

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 131

Plate 7-3 Reproductive System

Pubic symphysis Superior view Inferior (arcuate) pubic ligament

Inguinal ligament Deep dorsal vein of clitoris
(Poupart)
Transverse perineal ligament
PELVIC DIAPHRAGM II— Coccyx
FROM ABOVE Fascia of deep perineal muscles
Anterior
The pelvic diaphragm forms a musculotendinous, sacrococcygeal Urethra
funnel-shaped partition between the pelvic cavity and ligament
the perineum and serves as one of the principal supports Vagina
of the urethra, vagina, rectum, and pelvic viscera. It is Sacral promontory
composed of the levator ani and coccygeus muscles, Obturator canal
sheathed in a superior and inferior layer of fascia. The
muscles of the pelvic diaphragm extend from the lateral Obturator fascia
pelvic walls downward and medially to fuse with each (over obturator
other and are inserted into the terminal portions of the internus muscle)
urethra, vagina, and anus. Anteriorly, they fail to meet
in the midline just behind the pubic symphysis, expos- Tendinous arch of
ing a gap in the pelvic floor, which is completed by the levator ani muscle
urogenital diaphragm. This gap is partially filled by the
subpubic ligament that is pierced by the dorsal vein of Pubococcygeus muscle
the clitoris. In this area, the inferior fascia of the pelvic (part of levator ani muscle)
diaphragm fuses with the superior fascia of the urogeni-
tal diaphragm. Rectum

The levator ani muscles may be subdivided into an Ischial spine
anterior pubococcygeus and a posterior iliococcygeus
portion. They originate on each side at the posterior Iliococcygeus muscle
aspect of the pubis, the tendinous arch, and the ischial (part of levator ani muscle)
spine. They are inserted into the coccyx, the anococ- Coccygeus
cygeal body, the lower end of the anal canal, the central (ischiococcygeus) muscle
point of the perineum, the lower vagina, and the pos-
terolateral surface of the urethra. The levator ani Piriformis muscle
muscles are primarily supporting structures, but they
also contribute a sphincteric action on the anal canal Levator plate (median raphe)
and vagina. These muscles and their investing fascia of levator ani muscle
are critical to maintaining support for the vagina and
bladder. Rupture or stretch of this support system fol- Medial view
lowing pregnancy or childbirth is one of the major
causes of pelvic support defects (hernias) and the atten- Arcuate line of ilium Piriformis
dant problems of urinary incontinence and fecal reten- muscle
tion. It is to the tendinous arch (arcus tendineus) that Obturator internus muscle
some transabdominal approaches to the treatment of and obturator fascia (cut) Ischial
cysto-urethroceles provide anchorage or reattachment. spine
The levator sling is also the plate on which pessaries Tendinous arch of
must rest to provide mechanical support to prolapsing levator ani muscle Coccygeus
pelvic organs. (ischiococcygeus)
Obturator canal muscle
The pectineal ligament (also known as the inguinal
ligament of Cooper) is an extension of the lacunar liga- Iliococcygeus muscle Left levator ani
ment that runs on the pectineal line of the pubic bone, (part of levator ani muscle) muscle (cut)
seen as a ridge on the superior ramus of the pubic bone
and forming part of the pelvic brim. Lying across it are Rectum External anal
fibers of the pectineal ligament and the proximal origin sphincter muscle
of the pectineus muscle. This fibrous line has been used Urethra
clinically as an anchor point for incontinence proce- Superficial and deep
dures such as the Marshal-Marchetti-Krantz and Burch Pubococcygeus muscle transverse perineal muscles
procedures. (part of levator ani muscle)

The coccygeus muscles are triangular in shape, arise Sphincter urethrae muscle
from the ischial spine, and are inserted into the lateral
Left puborectalis muscle and
perineal membrane

Compressor urethrae and urethrovaginal Vagina
sphincter (portions of sphincter urethrae muscle)

borders of the lower sacrum and upper coccyx. They triangular and lies flattened against the posterior wall
lie on the pelvic aspect of the sacrospinous ligaments. of the pelvis minor. It originates from three or more
processes lateral to the first, second, third, and fourth
The fasciae of the pelvic diaphragm are continuous anterior sacral foramina and leaves the pelvis through
with the fascial layers of the perineal compartments— the greater sciatic foramen above the ischial spine to be
the endopelvic fascia, the obturator fascia, the iliac inserted by a rounded tendon into the upper border of
fascia, and the transversalis fascia of the abdomen. the greater trochanter of the femur. The obturator
internus muscles are fan-shaped and cover the side walls
Aside from the muscles of the pelvic diaphragm, two of the pelvis.
muscles—the obturator internus and the piriformis—
cover the walls of the true pelvis. The piriformis is

132 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 7-4 The Vagina

Ovary Mesovarium

Plane of section Uterus Uterine Broad ligament
(pulled up) (fallopian) tube
Angle of view Cut edge of peritoneum
Internal iliac Round forming floor of
artery and vein ligament paravesical pouch
of uterus
Suspensory
Ligament ligament of ovary
of ovary

SUPPORT OF PELVIC VISCERA Linea terminalis
(pelvic brim)

To clarify the relationships of muscles and fasciae in Cervix Uterine vessels
supporting the pelvis, with particular reference to the of uterus
vagina and internal female genitalia, the uterus, in the Cardinal (transverse
accompanying picture, has been elevated upward and Obturator cervical or
backward. The plane chosen for the section (small membrane Mackenrodt)
upper diagram) runs from a point anterior to the body ligament
of the uterus down through the anterior vaginal fornix Obturator
and along the longitudinal axis of the vagina to the fascia Tendinous arch
perineum. At this level, the large iliac vessels run close of levator ani
to the superior pubic rami which form the lateral pelvic Obturator muscle
walls. These pubic rami are connected to the ischiopu- internus muscle
bic rami across the obturator foramen by the obturator Vaginal artery
membrane, the obturator internus muscle, and the Levator ani muscle
obturator fascia. The broad ligaments begin at the (iliococcygeus and Ureter
lateral pelvic walls as double reflections of the parietal pubococcygeus
peritoneum, forming large wings, which divide to muscles) Uterovaginal fascia
include the uterus and separate the pelvic cavity into
anterior and posterior compartments. They are con- Ischiopubic ramus Anterior recess
tinuous with the peritoneum of the bladder anteriorly of ischioanal fossa
and the rectosigmoid posteriorly. The broad ligaments Compressor
contain fatty areolar tissue, blood vessels, and nerves, urethralis muscle Crus of clitoris
and at their apices invest the round ligaments, which
are condensations of smooth muscle and fibrous tissue Perineal membrane Ischiocavernosus
holding the uterus forward and inserting below and muscle
anterior to the fallopian tubes. The left ovary has been Artery of bulb of vestibule
lifted up to demonstrate the uteroovarian and infun- Fascia lata of thigh
dibulopelvic ligaments, the latter containing the ovarian Terminal part of round
blood supply. The bladder peritoneal reflection has ligament of uterus Superficial perineal space
been detached from the uterus, revealing the endopel-
vic or uterovaginal fascia, which runs laterally to the Sphincter urethrovaginalis muscle Perineal artery
pelvic wall as the cardinal ligament, and with the associ-
ated blood vessels, nerves, and fat forms the parame- Labium majus Superficial perineal
trium. The uterine arteries and veins extend medially (Colles) fascia
from their origins in the hypogastric vessels to the Labium minus
lateral vaginal fornices. The ureters (cross-sectioned) at Bulbocavernosus muscle and deep
this point pass beneath the uterine vessels and then Vestibule perineal (investing or Gallaudet) fascia
continue in the uterovaginal fascia medially and anteri-
orly across the upper vagina into the bladder. The close Vagina Bulb of vestibule
proximity of the ureters to the uterine blood supply and
vagina explains why they may easily be injured during triangular ligament, containing at this level the deep Vaginal wall
hysterectomy and in operations to repair lacerations of transverse perineal muscle and the artery of the clitoris.
the endopelvic fascia. The lower third of the vagina lies superficial to the Hymenal
pelvic diaphragm, and its opening into the vestibule is caruncle
The pelvic diaphragm is quite thin in cross section, bounded by the hymen and farther laterally by the ves-
contrasting sharply with its breadth. Although some of tibular bulb and its covering bulbocavernosus muscle. pad in the superficial perineal compartment, which is
the fibers of the levators come directly from the pelvic Close to the ischiopubic rami at the margin of the bony limited below by Colles fascia. The labia (majora and
brim, the main portion of the muscle originates from outlet of the pelvis are the crura of the clitoris, covered minora) lie superficial to Colles fascia and between the
the tendinous arch formed by a condensation of the medially by the ischiocavernosus muscles and the fat thighs. The muscles and fasciae below the triangular
fascia of the obturator internus. The levators here are ligament are concerned chiefly with coital function and
passing around the posterior vagina and enclosing the play no part in the support of the pelvic viscera. This
upper two-thirds of that organ. Below the levators and plate demonstrates the surgical implications of either
separated from them laterally by the upward extension the abdominal or vaginal approach to reconstruction of
of the ischiorectal fossa is the urogenital diaphragm or the elaborate supporting framework of the pelvic floor.

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 133

Plate 7-5 Reproductive System

Frontal section, anterior view

Ureteric orifice

Trigone of urinary bladder

Neck of urinary bladder

Detrusor muscle of bladder wall

Cavernous venous plexus of urethra

Levator ani muscle and
Fibromuscular extension

Urethra

Sphincter urethrae muscle

Perineal membrane

FEMALE URETHRA Bulb of vestibule

The urethra, situated at the lowest portion of the Bulbocavernosus muscle and deep
bladder and passing downward and forward beneath the perineal (investing or Gallaudet) fascia
symphysis, varies from 3 to 5 cm in length and averages
about 6 mm in diameter. The angle formed by the Round ligament of uterus (terminal part)
internal urethral orifice and the bladder at the bladder
neck and surrounded by the intrinsic sphincter is criti- Superficial perineal (Colles) fascia
cal to maintaining normal urinary continence; to with-
stand the hydrostatic pressure of the bladder, this area Lacunae and Openings of Labium majus
is further supported by the fascia and tensing muscles openings of paraurethral Labium minus
of the pelvic diaphragm. Its mucosal surface is thrown urethral glands (Skene) ducts
into longitudinal folds by the constricting action of the Schematic reconstruction
external supporting structures. The most prominent of
these longitudinal folds, situated on the posterior aspect Urethral glands Urethra
of the urethra, is sometimes referred to as the urethral
crest. The endopelvic fascia that covers the bladder is External urethral
continuous over the entire urethra just below the orifice
mucosal layer, and contiguous to it is a thin layer of
erectile tissue formed by the cavernous venous plexus. U Urethral canal Paraurethral Vagina
The muscular coats that surround the bladder also D Paraurethral duct (Skene) duct
cover the urethra but become thinner as it passes down- G Periurethral gland
ward toward the external meatus. The upper two-thirds V Thin-walled vein Opening of
of the urethra lie behind the symphysis pubis and are LP Lamina propria paraurethral
referred to as the intrapelvic urethra. It is this portion LM Longitudinal smooth muscle (Skene) duct
that passes through the musculofascial attachments CM Circular smooth muscle
forming the interlevator cleft. The perineal portion SM Striated (extrinsic) muscle Vaginal orifice
extends from the superior fascia of the urogenital
diaphragm to the meatus. As it passes through the uro- SM V
genital diaphragm, the urethra is surrounded by the CM DG
sphincter urethrae membranaceae, the homologue of
the muscle of the same name in the male but a far LM
weaker and less important structure. Near the external
meatus, the urethra is adjacent to the upper ends of the U
vestibular bulbs and the surrounding bulbocavernosus
muscles. At its meatus, the urethra lies in the anterior D LP
vaginal wall between the folds of the labia minora 2 to U G
3 cm below the clitoris. Along its entire length, but
especially in its perineal portion, the urethra is perfo- Low power High-power section through lower portion of urethra
rated by the openings of numerous small periurethral
glands, the homologues of the prostatic ducts in The submucosal lamina propria is a loose network of distal muscle groups have little to do with micturition.
the male. fibrous and elastic tissue containing a prominent venous Under high-power microscopy, it can be seen that the
system, the cavernous plexus or corpus spongiosum, epithelium of both the urethra and the periurethral
The schematic reconstruction of this duct system which accounts for the extreme vascularity in the area. ducts are of the stratified squamous type. The epithe-
shows that although the ducts of the small glands may The muscle coats consist of an inner longitudinal and lium of the intrapelvic portion of the urethra, as it
enter the urethra independently, the majority of them an outer circular layer, both quite thin and mutually approaches the bladder neck, tends to be transitional.
form an interdependent conducting system terminating interdependent. A thin layer of striated muscle referred The glandular epithelium, on the other hand, is of the
in the large paraurethral (Skene) ducts, which open on to as the external sphincter and supplied by the puden- columnar type, not infrequently stratified. The submu-
either side of the midline, posterior to the urethral dal nerve also surrounds the lower urethra, but these cosal connective tissue is relatively poor in cells.
meatus. These are vestigial remnants that serve no spe-
cific purpose but are important in that their position
predisposes them to infection, especially by the gono-
coccus, and that their relatively poor drainage increases
the risk of a chronic infection.

Cross sections through the lower urethra show the
mucosal folds and the immediate supporting structures:

134 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 7-6 The Vagina

Vaginal Wall

Epithelium
Papilla

Lamina propria

Blood vessels

VULVA AND VAGINA HISTOLOGY Smooth muscle
(circular and longitudinal)

The vagina is lined by squamous epithelium and capable Nerve ganglion
of dilation and constriction as a result of the action of
its supporting muscles and erectile tissue. The three External fibrous layer
principal layers are easily recognized in the cross section (endopelvic fascia)
through the vaginal wall. The epithelial surface is com-
posed of stratified squamous epithelium divided into Bartholin
basal cell, transitional cell, and spinal or prickle cell (major vestibular)
layers, also referred to as basalis, intraepithelial, and gland
functionalis. The superficial cells contain keratin but
normally show no gross cornification in women of Duct of Bartholin gland
reproductive age. The epithelium is slightly thicker transition from stratified
than the corresponding structure in the cervix and squamous to columnar epithelium
sends more and larger papillae into the underlying con-
nective tissue, giving the basement membrane an undu- Deep papilla Epithelium
lating outline. These papillae are more numerous on Cornified layer
the posterior wall and near the vaginal orifice. Beneath
the epithelium, which has a thickness of 150 to 200 μm, Minor vestibular gland
a dense connective tissue layer known as the lamina
propria is supported by elastic fibers crossing from the Blood vessels Labium minus Nerve Sebaceous gland
epithelium to the underlying muscle. These elastic
fibers, here and throughout the pelvis, are critical to than Bartholin glands. The mucus-secreting epithelium surface layer is clearly demarcated from the underlying
pelvic support and function. The lamina propria of these glands is tall, columnar, and one or two layers by its basement membrane and often by a thin
becomes less dense as it approaches the muscle, and in cells deep. area of edema. Close to the surface are located numer-
this area it contains a network of large, thin-walled ous small sebaceous glands but no hair follicles or fat
veins, giving it the appearance of erectile tissue. The The labium minus has an epithelium more deeply cells, in contrast to the labia majora. The connective
smooth muscle beneath this layer is divided into inter- pigmented than that of the vagina. The superficial tissue supporting the labium is acellular but rich in
nal circular and external longitudinal groups, the latter cells are more markedly keratinized and form a horny nerves and small vessels. The veins are not so numerous
being thicker and stronger and continuous with the (cornified) layer, which is especially prominent in post- or so large as those in the vagina and cannot be regarded
superficial muscle bundles of the uterus. No dividing menopausal women. The papillae of the lamina propria as erectile tissue.
membrane or fascia separates these two interlacing push deeply into the overlying epithelium, but the
muscle groups. The adventitial coat of the vagina is a
thin, firm, fibrous layer arising from the visceral or
endopelvic fascia. In this fascia and in the connective
tissue between it and the muscle runs another large
network of veins and, in addition, a rich nerve supply.

The Bartholin gland is situated just lateral to the
vaginal vestibule and appears in cross section as a col-
lection of small mucus-secreting glands lined by a single
layer of columnar epithelial cells with basally placed
nuclei. Occasionally, the columnar epithelium is strati-
fied. The small glands tend to be oval and symmetric
and are supported in a loose, vascular connective tissue.
The main Bartholin duct is lined by columnar epithe-
lium as it runs upward along the side of the vagina, but
as it nears its opening in the midportion of the lateral
wall of the vestibule, the epithelium takes on the strati-
fied squamous characteristics of the vaginal epithelium.
This transition accounts for the fact that malignant
tumors of Bartholin gland may be of either the adeno-
matous or the squamous type.

The minor vestibular glands, situated around the cli-
toris and urethra and aiding in the lubrication of the
vaginal surface, are of a more racemose, branching type

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 135